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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/principlespractiOOwarr 


THE 


PRINCIPLES  AND  PRACTICE 


SURGERY 


BY 

RICHARD  WARREN,  M.D.,  M.Ch.  Oxon.,  F.R.C.S. 

ASSISTANT    SURGEON  TO    AND    TEACHER  -OF  CLINICAL  SURGERY    AT    THE    LONDON    HOSPITAL; 

SENIOR  SURGEON  TO  THE   EAST  LONDON  HOSPITAL  FOR  CHILDREN;    EXAMINER  IN 

SURGERY  AT  THE   UNIVERSITY  OF  OXFORD  AND   TO  THE   SOCIETY 

OF  APOTHECARIES 


tUttb  266  ©rtgtnal  Tlllustrations 


VOLUME   I 


LEA    A    FEBIGER 

PHILADELPHIA    AND   NEW   YORK 
1916 


-  / 


v.l 


PBEFACE 

The  aim  of  this  book  is  to  place  before  the  reader  the  more  practical  issues 
of  Surgery,  from  the  standpoint  of  the  General  Surgeon.  Theoretical 
considerations  are  detailed  only  when  of  importance  in  diagnosis  or 
treatment.  Surgery,  of  late  years,  has  become  amazingly  complex,  and 
it  is  felt  that  a  need  has  arisen  for  simplification,  where  this  is 
possible.  Hence  several  of  the  more  classical  methods  of  treatment 
are  omitted  or  merely  referred  to,  and  those  alone  retained  which  bear 
the  hall-mark  of  practical  utility. 

Alternative  methods  of  treatment  are  discussed  only  where  the  course  of 
the  disease  or  the  condition  of  the  patient  renders  such  alternative  methods 
advisable.  Special  attention  has  been  paid  to  those  sections  where,  in  the 
last  few  years,  surgery  has  made  such  enormous  strides,  viz.  with  regard  to 
Blood-vessels,  Bones  (including  Fractures),  Joints,  the  Air  passages,  the 
Abdomen,  and  the  Urinary  System.  A  tolerably  full  account  has  been  given 
of  the  Surgery  of  the  Nose  and  Throat,  and  Air  passages,  while  the  Ear,  from 
its  close  association  with,  and  since  it  is  mainly  responsible  for  originating, 
pyogenic  diseases  of  the  Brain  and  Meninges,  is  described  in  the  section  on  In- 
fections of  the  latter.  In  dealing  with  such  an  extensive  subject  as  General 
Surgery,  there  are  many  portions  where  the  personal  experience  of  any  surgeon 
must  of  necessity  be  but  small,  and  much  assistance  has  been  derived  from  the 
ideas  and  writings  of  others.  As  far  as  possible,  however,  where  several  methods 
of  treatment  are  available,  attention  is  especially  directed  to  those  which  in 
the  personal  experience  of  the  writer  have  proved  sound  and  satisfactory. 
In  acknowledging  his  various  sources  of  information,  the  author  wishes  first 
to  render  grateful  tribute  to  the  teachers  of  his  own  hospital,  past  and 
present.  As  regards  information  derived  from  writings,  acknowledgment 
is  due  to  Adami  (General  Pathology),  Muir  and  Ritchie  (Bacteriology), 
the  many  textbooks  on  Surgery,  including  those  of  Treves,  Tillmanns,  Rose 
and  Carless,  Thomson  and  Miles,  and,  not  least, -i  The  Operations  of  Surgery  " 
by  Jacobson  ;  in  the  more  special  branches  to  Robert  Jones,  Tubby,  Whit- 
man (Orthopaedies),  to  Lane,  Hey  Groves,  Walton  (Fractures),  to  Robson, 
Moynihan5the  Mayos,  Barnard  (Abdominal  Surgery),  to  Coley,  Bloodgood, 


vi  PREFA<  I'. 

Baktead,  Bland-Sutton,  Eve  (Tumours),  to  Fenwick,  Kidd  (Urinary 
Surgery),  toSherren  (Injuries  to  Nerves),  to  Bfacewen,  Ballance,  J.  Hutchin- 
son .Inn.  (Cerebral  Surgery),  and  others  too  numerous  to  mention.  Special 
thanks  are  due  to  those  who  have  kindly  permitted  the  use  of  illustrations 

of  cases,  including  Messrs.  Hutchinson,  Kidd,  Milne,  Walton,  and  Dr. 
Gilbert  Scott ;  to  the  artists  Messrs.  Shiells,  Ford,  and  Ridgway.  who  have 
produced  finished  illustrations  from  rough  sketches  and  photographs ; 
to  Messrs.  Campbell  and  Maitland  for  help  in  reading  proofs  ;  and  finally 
to  Messrs.  J.  and  A.  Churchill  for  their  care  in  producing  this  work. 

RICHARD  WARREN 

Wimpole  Street 


CONTENTS 

SECTION  I 
INTRODUCTION  AND  GENERAL 

CHAPTER  I 

PAGES 

INTRODUCTORY i— 6 

CHAPTER  II 
BACTERIOLOGY 7—18 

Varieties  of  Bacteria :  Growth  :  Spores :  Products  of  Bacteria  :  Methods  of  Inves- 
tigating Bacteria  :  Koch's  Postulates  :  Saprsemia,  Septicaemia,  Bacillaamia  : 
Immunity  and  Defence  :  Vaccine  Therapy  :  Serum  Therapy. 

CHAPTER  III 
INFLAMMATION  AND  REPAIR 19—31 

General  Considerations  :  Simple  Inflammation  :  Healing  :  Varieties  :  Complica- 
tions and  Sequelae  of  Inflammation  :  Course  and  Termination  of  Inflamma- 
tion :  Acute,  Subacute,  and  Chronic  Inflammation  :  Diagnosis  :  Treatment. 

CHAPTER  IV 

DEGENERATIVE  AND  NECROTIC  SEQUELS    OF    INFLAMMATION- 
SUPPURATION  31—41 

CHAPTER  V 

DEGENERATIONS  AND  NECROSES— ULCERS  AND  GANGRENE  42—67 

Cell- degenerations  :  Varieties  of  Degeneration  :  Ulcers  :  Anatomy  and  Causes 
of  Ulcers  :  Healing,  Spreading,  and  Stationary  Ulcers  :  Treatment  of  Ulcers  : 
Skin  Grafting  :  Special  forms  of  Ulcers. 

Gangrene  :  Dry  and  Moist  Gangrene  :  Clinical  Appearances  :  Traumatic  Gan- 
grene :  Nontraumatic  Vascular  Gangrene  :  Infective  Gangrene. 


viii  CONTENTS 

CHAPTER  VI 

PAGES 

I.  NEW  GROWTHS.     II.  CYSTS 68—109 

Classification,  Innocent  and  .Malignant  :  Classification  from  origin  and  from 
.-tincture  :  .Etiology  :  Irritation,  parasites,  "  rests  "  :  Local  and  general 
malignancy  :  Metastases  and  their  methods  of  formation  :  Teratomas  :  Der- 
moids :  Mixed  tumours  (renal,  salivary)  :  Blastoiias  :  Chorio-epithelioma  : 
Lkpidomas  :  Papillomas  :  Adenomas  :  Cancers  :  Transitional  lepidomas  : 
.Mesotheliomas  :  Endotheliomas  :  Angeiomas  :  Melanomas  :  Hyi.omas  :  Neu- 
romas :  Fibromas  :  Lipomas  :  Chondromas  :  Osteomas  :  Tumours  of  bone- 
marrow  :  Myomas  :  Myxomas  :  Sarcomas  :  Diagnosis  of  tumours  :  Treatment. 
Cysts — embryomic,  inflammatory,  parasitic,  glandular,  degeneration. 

CHAPTER  VII 
GENERAL  CONDITIONS  OF  SURGICAL  IMPORTANCE         .  .      no— 121 

Fever  :  Delirium  :  Syncope,  Shock  and  Collapse  :  Surgical  aspects  of  General 
Intoxications  :  Alcohol  :  Renal  Disease  :  Diabetes  :  Acidosis  :  Changes  in  the 
Blood. 

CHAPTER  VIII 

GENERAL  SURGERY  OF  INJURIES 122—133 

.Mechanical  Injuries  :  Bruising  :  Baematoma  :  Haematoccele :  Wounds:  Varieties 
and  Treatment  of  Wounds  :  Effects  of  Heat  and  Cold  :  burns  :  Frostbite  : 
Corrosive  Fluids  :  Electrical  Discharges  :  X-rays  :  Thermic  Fever. 

CHAPTER  IX 
GENERAL  PRINCIPLES  OF  SURGICAL  TECHNIQUE  .  .      134—155 

Anaesthesia  :  General  Anaesthesia  :  Varieties  :  Insufflation  Anaesthesia  :  Guides 
in  Anaesthesia  :  Dangers  :  Local  Anaesthesia  :  Nerve  blocking  :  Spinal  An 
thesia  :  Choice  of  Anaesthetc  :  Asepsis  and  Antisepsis  :  Sterilization  :  Anti- 
septics (Chemical)  :  Preparations  for  Operation  :  The  boom,  the  Patient,  the 

Surgeon  and  Assistants  :  Materials  used  for  Operations  :  Ligatures  :  Dress- 
ings :  Incisions  :  Suturing  the  skin  and  deeper  parts  :  Drainage  :  After- 
treatment. 

CHAPTER  N 

PARASITIC  AND  INFECTIVE  DISEASES 156—218 

Varieties  of  Infection  :  Specific  Infection  and  its  Diagnosis,  Agglutinating 
Tests,  Deviation  of  the  Complement  (serum  reaction)  :  General  Infections  : 
Septicaemia  :  Pyemia  :  Special  Infections  :  Pyogenic  Organisms  :  Staphy- 
lococci, Carbuncle  :  Streptococci,  Erysipelas,  Cellulitis  :  Cellulitis  of  special 
regions  :  Pneumococci  :  Gonococci  :  Soft  Sore  :  Glanders  :  Anthrax  :  Organ- 
isms found  in  Spreading  Gangrene  :  \  Incent's  Organisms  :  Diphtheria  :  Teta- 
nus :  Hydrophobia  :  Streptothrices  or  Mycobacteria  :  Tuberculosis  :  Modes  of 
Infection  and  Predisposing  causes  :  Anatomy  and  results  of  Tuberculous  In- 
fection :  Treatment  :  Actinomycosis  :  Leprosy  :  Protozoal  Diseases  :  Dysen- 
tery :  Malaria  :  Delhi  Boil :  Syphilis  :  Acquired  and  congenital  forms  :  Stages  : 
Forms  of  Chancres  :  Secondary  and  Tertiary  manifestations  ;  Colles's  Law  : 
Diagnosis  of  Syphilis  :  Prognosis  and  Infectivity  :  Treatment  of  Syphilis  : 
Yaws  :  Hvdatid  disease. 


I  ONTENTS  ix 


SECTION  II 


SURGERY  OF  THE  SKELETOMOTOR 
SYSTEM 


CHAPTEB  XI 

PAOl  3 

INJURIES  OF  THE  SKELETOMOTOR  SYSTEM  (GENERAL)  .      219—256 

Injuries  of  Bones  :  Contusions  :  Fractures  :  Varieties  and  terms  :  Separated 
epiphyses:  Genera]  Pathology  of  Fractures  and  their  repair :  Signs :  General 
ilta  "1  Fractures  :  Treatment  in  genera]  :  First-aid  :  Reduction  :  Xon- 
operative Treat menl  :  Extension  :  Fixation  :  Splints  :  Plaster:  Indications 
for  air  1  Methods  of  <  Operative  Treatment  :  <  Obstacles  to  Reduction  :  Mass 
Complications  of  Fractures  :  <  lompound  Fractures  :  Complications  with 
Joints, Vessels, Nerves  :  Non-union  and  mal-union  :  General  complications: 
Pneumonia  :  Crutch  Palsy.  219     i\j 

Injuries  of  Joints  ;  Sprains  :  Wounds  :  Dislocations  :  Causes  :  Reduction  of 
Dislocations,  and  difficulties.  247     253 

Rupture  ol  Muscles  and  Tendons  :  Dislocation  of  Tendons  :  [schsemic  Contri 

tare  of  Muscles.  253 — 256 

«  il.VPTER  XII 

INJURIES  OF  SPECIAL  REGIONS,  CHIEFLY  REFERRING  TO  FRAC- 
TURES. DISLOCATIONS  AND  INJURIES  TO  MUSCLES  AND 
TENDONS 257—346 

Injuries  aboul  the  inner  end  of  the  Claviele  :  Fractures  of  the  Shaft  of  the 
Clavicle:  Injuries  about  the  Shoulder :  Of  the  Scapula :  Of  the  Arm  and  Shaft 
of  the  Bumerus  :  <  M  the  Elbow-joinl  :  <  )f  the  Forearm  :  '  >f  the  Wrist  :  <  >f  the 
Band  and  Fingers:  Of  the  Pelvis:  Of  the  Bip:  Of  the  Femoral  Shaft  :  Of  the 
Knee  :  Of  the  Tibia  and  Fibula  :  Of  the  Ankle  :  Of  the  Foot. 


(  1LAPTER  XIII 

DISEASES  OF  BONES,  JOINTS,    MUSCLES,    TENDONS    AND    BURSiE  : 

EXCISIONS  AND  AMPUTATIONS 347—434 

Anatomy  and  Growth  of  Bone  :  General  Pathology  of  Bone  :  Congenital 
Affections  :  Rickets  :  Delayed  Rickets  :  Mollities  Ossium  :  Infantile  Scurvy: 
Acromegaly  :  Osteomalacia  :  Pulmonary  Osteo-arthropathy  :  Cretinism  : 
Osteitis  Deformans  :  Leontiasis  I  ►ssea  :  Infective  Diseases  of  Hone:  Pyogenic 
Infections  :  Periostitis  and  Diaphysitis  :  Juxta-epiphysea]  Infections.  Acute 
and  chronic  |  Brodie'a  Abscess)  :  Diaphysectomy,  Sequestrotomy  :  Tubercu- 
losis and  Syphilis  of  Bone  :  Typhoid  Infection  of  Bone  :  Hydatids  :  New 
Growths  and  Cysts  of  Bone  :  Osteomas  :  Exostoses  :  Chondroma  :  Lipoma: 
Sarcoma  :  Myeloid  Sarcoma  :  Operations  on  Bones  :  Repair  of  defects  in 
Bone.  347—390 

Joints  :  General  Considerations  and  Examination  :  Synovitis  :  Arthritis  : 
Ankylosis  :  Baker's  Cysts  :  Acute  Infections  :  Subacute  Infections  :  Tubercle 
and  Syphilis  :  Treatment  :  Arthrectomy  and  Excision  :  The  Rheumatoid 
Affections  :  Osteo-arthritis  :  Chronic  Gout  :  Charcot's  Joints  :  Hemophilic 


x  CONTENTS 

DISEASES  OF  BONES,  ETC.     continued 

r\..i  B 

Joints :  Neoplasms  of  Joints:  Functional  affections  of  Joints :  Operations  on 

Joints.  390 

Affections   i>f   Muscles  :   Paralysis    and    Spasm  :   [nflammations    :    Myositis 
oans  :  Affections  of  Tendons  :  Acute  Tenosynovitis  :  chronic  Teno- 

BynoTitis  and  Ganglia :  Operations  on  Tendon  and  Muscles:  Bursitis.     420 — 428 
Amputations   :    General   Considerations   :    Technique   :    Various    Methods   : 

Artificial  Limbs.  428 — 434 

CHAPTEB  XIV 

REGIONAL  SURGERY  OF  THE  SKELETOMOTOR  SYSTEM  .     435—557 

Affections  of  the  Spine  :  Anatomy  and  Examination  :  Acute  Pyogenic  Infec- 
tions: Tuberculosis  of  the  Spine :  Syphilis  and  Typhoid  Infect  ii  tn  of  the  Spine : 
Rheumatoid  Affections  of  the  Spine  :   Static  Deformities  of  the  Spine    : 

Tumours  of  the  Spine  :  The  Xeek  :  Cervical  Ribs  :  Torticollis  :  The  (  la\  icle, 
Acute  Infections  :  NewGrowths  :  Excision  of  the  Clavicle  :  The  Scapula-  Con- 
genital Defects,  Winged  Scapula  :  Infections  and  Tumours  :  Excision  of  the 
Scapula  :  Affections  of  the  Shoulder,  Flail  Shoulder  :  Infections — Pyogenic, 
Tuberculous  :  Ankylosis  :  Operations  at  the  Shoulder  :  Amputation  of  the 
entire  Upper  Limb  :  The  Humerus  -Affections  and  Amputations  through  : 
The  Elbow  :  Tuberculosis — Operations  :  The  Forearm — Congenital  Defects, 
Infections  :  Amputations  :  The  Wrist  :  Tuberculosis — Excision  :  Deformities 
of  the  Hand  and  Fingers  :  Infections  of  the  Hand  and  Fingers  :  Amputation 
of  the  Hand  and  Fingers  :  The  Pelvis — Infections  and  Tumours  :  Interileo- 
abdominal  Amputation  :  The  Buttock  :  The  Hip — Congenita]  Dislocation, 
Snapping  Hip,  Acute  Arthritis,  Tuberculosis,  Rheumatoid  Affections,  Coxa 
Vara,  Ankylosis,  Bursa;  :  Treatment  :  Operations  at  the  Hip  :  The  Femur  : 
The  Knee — Acute  Infection,  Tuberculosis,  Operative  Treatment :  Deformit  ies 
of  the  Knee — Genu  Varum  and  Valgum  :  Operations  about  the  Knee  :  The 
Leg — Infections,  Tumours,  Operations  :  The  Ankle,  Operations  and  Amputa- 
tions :  Club-foot  :  Flat-foot  :  Hallux  Valgus,  &c.  :  Paralyses  in  children  and 
their  results  :  Operations  on  the  Feet  and  Toes. 


SECTION  III 

SURGERY  OF  THE  NERVOUS  SYSTEM 
AND  EAR 

(  HAPTER  XV 

AFFECTIONS  OF  THE  SCALP,  SKULL,  BRAIN,  EAR  AND 

SPINAL  CORD 558—653 

The  Scalp — Injuries  :  Inflammations  :  Tumours. 

The  Cranium — Congenital  Defects  :  Injuries  :  Simple  Fractures  :  Compound 
Fractures  :  Depressed  Fractures  :  Operations  :  Fractures  of  the  base  of  the 
Skull  :  Infections  of  the  Cranium  :  Pyogenic  :  Syphilis  :  New  Growths. 

The  Brain  Genera]  considerations  :  Cerebro-cranial  topography  :  Cortical 
areas,  Genera]  Diagnosis  :  Methods  of  Opening  the  Skull  :  Concussion  of  the 
Brain  :  Cerebral  Irritation  :  Acute  Compression  of  the  Brain  :  Intracranial 
Bsemorrhage  (Extradural,  intradural):  Laceration  of  the  Brain  :  Penetrating 
Wounds  :  Bullets  :  Intracranial  Inflammation.  558 — 601 


CONTENTS  xi 

PAGES 

The  Ear — Anatomy,  Relations,  and  Diagnosis  :  The  External  Ear  :  Foreign 
bodies  :  Inflammations  :  Tumours  :  The  Middle  Ear  :  Inflammations  : 
Eustachian  Catarrh  :  Acute  Otitis  Media  :  Chronic  Suppurative  Otitis  : 
Otosclerosis  :  Polypi  :  Caries  of  the  temporal  bone  :  Mastoiditis  :  Operation 
for  Inveterate  Otitis  Media  and  its  complications  :  Intracranial  complications 
of  Otitis  Media :  Extradural  Abscess  :  Subdural  Inflammations  :  Acute  and 
Chronic  Lepto-meningitis  :  Subdural  Abscess  :  Thrombosis  of  Intracranial 
Sinuses  :  The  Lateral  Sinus,  the  Cavernous  Sinus  :  Encephalitis  :  Otitic 
Cerebral  Abscess  and  Cerebellar  Abscess. 

Other  Cerebral  Abscesses  :  Hernia  Cerebri  :  Epilepsy  :  The  Traumatic- 
Neuroses  :  Cerebral  Tumours  :  Operations  :  Hydrocephalus.  60 1 — 639 

The  Spinal  Cord  :  Anatomy  :  Diagnosis  :  Laminectomy  :  Congenital  affections  : 
Injuries  of  the  Spine  :  Fracture-dislocations  :  Injuries  of  the  Cord  :  Compres- 
sion Myelitis  :  Tumours  of  the  Cord.  639 — 653 


CHAPTER  XVI 

AFFECTIONS  OF  THE  PERIPHERAL  NERVES  .  .  .     654—698 

General  Considerations  :  Examination  :  Injuries  of  Nerves  :  Pseudo-neuromas  : 
Recovery  after  Injuries  :  Treatment  :  Neuritis  :  Neuralgia  :  Tumours  of 
Nerves  :  Special  Nerves  :  The  Cranial  Nerves  :  Trigeminal  Neuralgia  :  Opera- 
tions :  The  Facial  Nerve  :  Operations  :  The  Cervical  Plexus  :  The  Brachial 
Plexus  :  The  Musculo-spiral,  Ulnar,  and  Median  Nerves  :  The  Cauda  Equina  : 
The  Sciatic  Nerve  :  Sciatica. 


INDEX at  end 


SECTION  I 
INTRODUCTORY  AND  GENERAL 


CHAPTER  I 

INTRODUCTORY 

Surgery  of  the  present  day,  though  essentially  a  handicraft  or  art,  has 
become  evolved  far  beyond  the  ancient  craft  of  the  Barber- Surgeon  and  is 
based  on  Science.  Manual  dexterity  must  be  directed  by  an  intelligent 
brain  to  attain  the  higher  realms  of  this  art,  and  both  the  scientific  and 
artistic  sides  of  this  branch  of  medicine  are  to  be  carefully  cultivated  in 
order  to  produce  fine  surgery.  Good  hands  are  in  part  a  natural  gift,  but 
one  which  can  be  improved  vastly  by  practice.  The  manipulations  of  the 
surgeon  are  so  manifold  in  their  technique  and  so  many  varieties  of  structural 
texture  are  encountered  that  modern  surgery  has  points  in  common  with 
carpentering  and  engineering,  not  to  mention  tailoring,  plumbing,  &c,  and 
an  understanding  of  the  principles  of  these  crafts  is  needed  to  bring  surgical 
art  to  perfection.  How  often  does  one  feel  that  a  surgeon  is  a  good  tailor 
but  a  bad  carpenter,  or  vice  versa,  and  no  surgeon  regrets  in  after  life  his 
boyish  efforts  at  the  carpenter's  bench !  Success  in  the  practice  of  surgery 
depends  largely  on  attention  to  detail  and  in  treating  each  case  on  its  merits. 
The  modern  surgeon  seldom  performs  "set"  operations  and  is  constantly 
modifying  his  methods  to  suit  the  requirements  of  individual  patients.  In 
order  to  apply  manual  dexterity  to  the  best  advantage,  judgment,  "  seven 
times  tried,"  and  much  discrimination  are  necessary,  and  this  constitutes 
the  scientific  or  intellectual  side  of  surgery.  A  surgeon  should  be  a  thoughtful 
sceptic,  always  prepared  to  find  fallacies  in  orthodox  theories  if  the  latter 
do  not  fit  in  with  the  facts  observed.  It  is  our  misfortune  that  we  are  apt 
to  take  too  much  for  granted,  believing  what  is  told  us  by  "  authorities  " 
and  not  reasoning  sufficiently  often  nor  deeply  enough  on  our  own  observa- 
tions, and  so  weighing  the  true  value  of  theories.  Accurate  observation 
of  the  facts  of  diseases  and  the  results  of  various  methods  of  treatment  is 
of  the  utmost  importance  in  surgery  as  in  other  sciences,  and  is  seldom 
attained  but  by  much  care  and  long  training.  In  fine,  a  surgeon  should 
be  a  rational  observer  of  disease,  deducing  from  his  observations  a  diagnosis 
and  line  of  treatment.  The  former  may  be  tentative  and  often  depending 
on  operative  measures  for  verification  as  well  as  for  treatment  ;  for  it  must 
be  recognized  at  once  that  in  many  conditions,  e.g.  suspected  cancer  of  the 
stomach  or  intestine,  operative  measures  form  a  rational  means  of  diagnosis, 
i  1  i 


2  A  TEXTBOOK  OF  SURGERY 

Treatment  is  based  as  far  as  possible  on  rational  grounds,  but  will  often 
be  fundamentally  empirical,  for  it  must  be  admitted  that  though  based  on 
intelligent  ratiocination,  surgery  is  by  no  means  an  exact  science  like  mathe- 
matics, and  it  is  in  practice  often  advisable  to  adopt  a  line  of  treatment 

the  exact  working  of  which  is  nut  absolutely  clear,  since  it  is  our  aim  to  do 
the  best  we  are  able  for  each  patient.  Further,  it  is  well  to  hold  a  modest 
scepticism  as  to  the  results  of  our  treatment,  and  not  too  readily  to  regard 
these  results  as  final.  -Modern  surgery  has  reached  a  degree  of  great  com- 
plexity ;  several  branches  claim  specialists  devoted  to  little  else,  who  by 
research  and  experiment  have  greatly  advanced  their  art.  Nevertheless 
surgery  still  exists  as  a  fairly  distinct  entity  separated  from  Internal 
Medicine,  Gynaecology,  Ophthalmology,  &c,  although  there  are  signs  of 
cleavage,  notably  in  the  cases  of  affections  of  the  Ear,  Nose,  and  Throat, 
and  Orthopaedics;  while  the  advance  in  abdominal  surgery,  especially  of 
the  upper  abdomen  (liver  and  stomach),  is  tending  to  produce  a  race  of 
Operating  Internists  who  are  physician  and  surgeon  alike,  and  the  same 
is  •  equally  true  of  Urinary  Surgery.  This  excessive  specialization  is  not 
without  its  dangers,  tending  to  produce  surgeons  who  can  see  but  one  form 
of  disease — that  on  which  they  are  accustomed  to  operate ;  hence  a  wide 
acquaintance  with  general  surgery  is  advisable  before  such  specialities 
alone  are  undertaken.  Temperament  is  perhaps  the  quality  most  desirable 
for  the  surgeon  and  least  easy  to  attain  by  taking  thought.  The  surgeon 
must  aim  at  forming  swift  but  sound  judgments  ;  he  must  be  firm  of  purpose 
and  ever  be  ready  to  seize  the  golden  opportunity  which  may  convert 
apparent  defeat  into  certain  victory,  for  sudden  urgencies  may  arise  in  the 
simplest  and  most  prosaic  operation,  and  with  but  the  slightest  warning  : 
under  such  conditions  a  steady  head  unaffected  by  the  vertigo  of  excitement 
is  essential  to  avoid  disaster.  As  regards  the  more  scientific  side,  training 
in  surgery  is  based  on  the  same  anatomical  and  physiological  basis  as  the 
other  branches  of  medicine,  and  consequently  we  commence  with  a  considera- 
tion of  pathology,  upon  which  as  a  foundation  the  structure  of  sound  surgery 
must  be  reared. 

GENERAL   PATHOLOGY 

Pathological  changes,  i.e.  departure  from  the  normal  in  the  structure 
and  function  of  an  organism,  may  be  classified  according  to  the  processes 
involved  in  these  changes,  or  from  the  causes  producing  such  changes. 

The  outstanding  pathological  processes  with  regard  to  structure  are  : 

(1)  Inflammatory,  reparative,  and  developmental  processes,  or  "  growth 
pro  esses." 

(2)  Degenerations,  necroses  (often  the  sequela?  of  inflammations),  or 
processes  tending  towards  "  death." 

(.'})  The  formation  of  new  growths  or  tumours,  or  growth  of  "  heterodox 
nature." 

The  causes  of  pathological  conditions  may  be  classified  as  follows  : 
(1)  Congenital  defects. 


CONGENITAL  DEFECTS  3 

(2)  Injuries,  by  which  is  implied  macroscopic  insult  to  the  tissues,  blows, 
crushes,  cuts,  burns,  electrical  discharges,  &c. 

(3)  Infections,  i.e.  microscopic  injuries  to  the  tissues  from  the  growth 
of  micro-organisms  and  their  products.  In  a  practical  classification  infec- 
tions and  inflammations  are  often  grouped  together,  since  the  more  important 
inflammations  result  from  infection  :  still  it  should  be  noted  that  inflamma- 
tions may  result  from  injury,  e.g.  sprains  of  joints,  the  effect  of  foreign  bodies 
in  the  conjunctival  sac,  &c.  ;  while  infections  may  not  produce  inflamma- 
tions, e.g.  tetanus. 

(4)  Intoxications  or  effects  of  poisons  :  whether  from  metallic  or  organic 
bodies,  e.g.  arsenic,  alcohol,  or  the  products  of  infective  organisms,  e.g. 
tetanus,  diphtheria,  all  of  which  may  be  called  exogenous  intoxications  : 
besides  these  are  the  endogenous  intoxications  or  auto-intoxications  resulting 
from  abnormal  processes  of  some  secretory  organs  of  the  body,  as  defects 
in  the  secretion  of  the  thyroid,  pituitary,  or  the  suprarenal  bodies,  leading 
to  the  diseases  known  as  myxcedema,  Graves's  disease,  acromegaly,  Addison's 
disease,  &c. 

In  addition  to  these  fundamental  causes  and  processes  of  disease  secon- 
dary conditions  arise,  such  as  the  formation  of  calculi  in  hollow  viscera  ; 
stenosis  of  organs  or  their  ducts,  and  the  results  of  this  ;  alteration  in  the 
function  of  organs  from  alteration  in  nervous  and  blood-supply  resulting 
in  deformities,  &c. 

Alterations  of  function  may  be  of  general  nature,  such  as  fever  and 
shock,  or  confined  more  especially  to  some  part  or  organ,  as  retention  of 
urine,  intestinal  obstruction,  &c. 

In  considering  the  diseases  of  regions  and  organs  division  will  be  made 
on  the  following  lines,  partly  on  causation,  partly  on  pathological  changes  : 
(1)  Congenital  defects;  (2)  Injuries;  (3)  Infections  and  inflammations; 
(4)  Degenerations  and  secondary  changes  ;   (5)  New  growths. 

Congenital  Defects.  These  occur  with  varying  frequency  and 
importance  in  different  parts  of  the  body,  in  some  regions  being  so 
rare  as  to  be  practically  negligible,  in  others  frequent  and  of  great 
importance. 

Thus  congenital  errors  in  the  descent  of  the  testis  are  extremely  common, 
resulting  in  the  production  of  hernia,  undescended  and  ectopic  testes. 
Improper  development  of  the  nasal  and  buccal  cavities,  resulting  in  hare- 
lip and  cleft  palate,  are  also  not  uncommon.  While  far  from  rare  and  of 
great  importance  are  deformities  of  the  extremities,  especially  the  lower, 
known  as  "club  foot,"  the  early  and  correct  treatment  of  which  converts 
useless  cripples  into  useful  members  of  society. 

Briefly,  congenital  deformities  may  be  divided  into  (1)  those  due  to 
some  primitive  defect  in  the  embryo  itself,  and  (2)  those  due  to  some  cause 
acting  in  utero  apart  from  the  embryonic  development. 

(1)  Under  the  former  heading  we  find  : 

(a)  Excessive  or  diminished  formation  of  parts,  limbs  or  organs,  either 
in  size  or  numbers.     In  the  former  group  may  be  noted  :    supernumerary 


A  TEXTBOOK  OF  SURGERY 


Fig.  1.     -V  cessory  digits. 


digits  and  nipples  (Fig.  1);  local  overgrowth  of  limbs.    In  the  latter  absence  ol 
breast,  kidney,  &c. 

(b)  Improper  union  of  portions  which  six >ul«!  unite,  or  failure  to  open 
of  apertures,  which  should  become  patent.  In  the  first  group  are  clefl 
palate,  hare-lip,  congenital  hernial  sacs,  branchial  fistulse,  and  cysts.  In  the 
latter,  congenita]  narrowing  or  even  complete  obstruction  of  the  intestinal 
canal,  in  tin'  duodenum,  oesophagus,  rectum,  of  the  ureters,  urethra,  &c. 

(<•)  Teratomas  or  addition  of  parts  of  a  second  foetus  to  the  main  body 
of  tin-  patient,  including  ovarian  dermoids,  conjoined  foetuses,  &c,  which 

are  further  considered  under 
the  heading  "Tumours  or 
New  Growths." 

(2)   ruder  the  latter  head- 
ing are  : 

The  results  of  causes  act- 
ing in  utero  independent  of 
the  growth  of  the  embryo, 
such  as  the  effect  of  constric- 
tion by  amniotic  bands  or  the 
umbilical  cord,  resulting  in 
constrictions  or  amputation 
of  limbs,  to  which  may  per- 
haps be  added  some  forms  of 
club  foot  from  excessive  intra-uterine  pressure.  Finally,  infective  disease, 
such  as  syphilis,  may  produce  congenital  disease,  though  conditions  of  this 
nature  are  usually  classified  with  the  disease  of  similar  nature  occurring  in 
a  patient  after  birth. 

Injuries  or  Trauma.  The  term  injury  is  loosely  and  by  custom 
applied  to  the  results  on  the  tissues  caused  by  injuries,  since  the  result  of 
gross  insults  to  tissues  makes  a  practical  group. 

Pathologically,  the  results  of  injuries  may  be  regarded  as  solution  or 
breach  of  continuity  of  skin,  muscles,  bones,  blood  and  lymph  vessels.  &c, 
with  effusion  of  blood  and  lymph,  necrosis,  and  degeneration  of  tissue, 
together  with  Inflammatory  and  reparative  efforts  on  the  part  of  the  tissues. 
As  the  result  of  injuries  of  different  sorts  varies  it  is  useful  for  descriptive 
purposes  to  classify  injuries  as  those  from  sharp,  blunt,  or  crushing  violence. 
from  burns,  scalds,  corrosive  fluids,  electricity,  X-rays,  &c,  and  these  will 
be  considered  in  detail  in  a  later  section. 

Infections  and  Inflammations.  Inflammation  and  the  allied  condi- 
tions, repair,  degeneration,  suppuration,  ulceration,  necrosis,  gangrene, 
form  a  very  large  part  of  the  processes  of  pathology.  Moreover,  infection 
is  a  most  important  setiological  factor  in  these  conditions,  though  injuries 
and  new  growths  are  often  responsible,  so  that  some  detailed  consideration 
of  inflammation  will  be  needed. 

The  discussion  of  infections  will  need  a  brief  preliminary  stud}'  of  bacteria. 
since  the  prophylaxis  of  infection,  under  the  name  Asepsis,  is  almost  more 


DEGENERATIONS 


important  than  the  cure  of  infection  in  modern  surgical  practice,  and  is 
based  on  a  knowledge  of  bacteriology. 

Intoxications.  The  results  of  poisoning  are  of  no  small  importance  in 
surgery,  though  perhaps  coming  more  under  notice  in  medical  work. 

In  treating  the  results  of  poisoning  with  the  more  usual  drugs  and 
chemical  substances  the  surgeon  is  confined  to  dealing  with  local  effects, 
such  as  stomatitis  in  mercurialism,  necrosis  in  phosphorus  poisoning, 
relieving  stenosis  of  the  oesophagus  or  pylorus  resulting  from  corrosive 
poisons.  &c.  More  important  in  surgery  are  the  effects  of  poisons  produced 
by  infective  organisms  about  which  little  is  known  chemically,  but  which 
are  responsible  for  the  general  effects  of  infection,  fever,  wasting,  and  the 
various  cell  degenerations  described  later,  including  cloudy  swelling,  amyloid 
or  laidaceous  degeneration, 
fatty  degeneration,  &c. 

Of  late  years  the  study  of 
the  auto-infections  has  led  to 
much  improvement  in  the 
knowledge  and  art  of  surgery. 
Thus  certain  diseases  of  the 
thyroid  and  pituitary  bodies 
are  coming  to  be  regarded  as 
suitable  for  surgical  interfer- 
ence, while  such  conditions  as 
acidosis,  renal  insufficiency, 
cholaemia,  &c,  have  to  be 
taken  into  account  when  oper- 
ative measures  are  contem- 
plated. 

Degenerations.  Degener- 
ative changes  in  cells  and 
tissues  follow  as  sequelae  to 
inflammations,  usually  of  infec- 
tive origin,  from  intoxications, 
or,  in  consequence  of  impairment  of  the  vascular  and  nervous  supply  to  ihe 
part  involved  ;  old  age  and  disuse  are  fertile  sources  of  degeneration.  In 
some  instances  the  cause  of  degeneration  is  unexplained. 

As  instances  of  degeneration  we  may  instance  cloudy  swelling,  fatty, 
fibrous,  calcareous  changes,  and  amyloid  degenerations,  usually  following 
in  the  train  of  infective  inflammations  and  intoxications. 

Atrophy  is  a  familiar  form  of  degeneration  exampled  by  the  wasting 
of  bones  and  muscles  from  prolonged  rest  in  splints  (Fig.  2),  or  from  old  age. 
Hypertrophy  is  the  antithesis  of  atrophy  and  should  be  regarded  as  physio- 
logical, not  pathological ;  the  well-known  hypertrophy  of  muscles  dependent 
on  certain  trades  or  athletic  exercises  may  be  instanced  :  or  the  compensa- 
tory overgrowth  where  there  is  seme  deficiency  to  be  overcome,  e.g.  growth  of 
intestinal  or  bladder  muscle  to  overcome  some  obstruction  in  the  intestine 


Fig.  2. 


Old  standing  tuberculosis  of  left  hip,  with 
atrophy  of  the  femur  from  disuse. 
(From  a  skiagram). 


6  A  TEXTBOOK  OF  SURGERY 

01  urethra  :  the  increase  in  size  of  a  solitary  kidney  from  the  increased 
work  put  upon  it :  the  changes  in  a  lactating  breast  may  also  be  regarded 
as  hypertrophy. 

This  term  is  also  loosely  applied  to  any  overgrowth  of  tissues  or  organs 
independent  of  use.  Thus  the  breast  may  enlarge  uselessly  quite  apart 
from  inflammations  or  new  growths.  Again,  excessive  growth  of  certain 
bones  takes  place  in  affections  of  the  pituitary  body.  It  is  better  to  retain 
the  term  hyperplasia  for  such  conditions,  while  hypertrophy  is  reserved 
for  overgrowth  associated  with  increased  amount  of  work  performed  by 
the  part  in  question. 

Secondary  Pathological  Processes.  A  number  of  diverse  conditions 
may  be  included  under  this  heading,  such  as  the  formation  of  calculi  in 
hollow  organs  ;  stenosis  and  obstruction  of  viscera  as  instanced  by  intestinal 
obstruction,  urethral  stricture  ;  changes  following  affections  of  nerves  and 
vessels  of  which  paralytic  and  spastic  deformities,  various  forms  of  ulcera- 
tion, gangrene,  embolic  processes,  &c,  are  common  examples. 

New  Growths,  Neoplasms,  or  Tumours  are  generally  defined  as  forma- 
tion of  new  tissue  having  no  physiological  use  and  no  typical  termination. 
The  first  point  separates  them  from  hypertrophy,  where  use  increases  with 
overgrowth  ;  the  second  from  inflammation,  where  new  formation  of  tissue 
always  ends  in  absorption,  suppuration,  fibrosis,  sloughing,  &c.  Perhaps 
the  simplest  conception  of  new  growths  is  to  regard  them  as  the  result  of 
the  assumption  of  independent,  parasitic  properties  by  certain  cells  of  the 
body  which  grow  independently  of  any  useful  purpose  and  in  a  perfectly 
selfish  manner. 


CHAPTER  II 
BACTERIOLOGY 

Varieties  of  Bacteria  :  Growth  :  Spores  :  Products  of  Bacteria  :  Methods  of 

Investigating   Bacteria  :  Koch's   Postulates  :  Sapraemia,  Septicaemia,  Bacil- 

laemia  :  Immunity  and  Defence  :  Vaccine  Therapy  :  Serum  Therapy. 

Modern  surgery  is  largely  based  on  the  knowledge  which  has  been  acquired 
in  recent  years  of  the  life  and  actions  of  those  minute  organisms  known 
as  bacteria,  bacilli,  germs,  or  microbes,  as  well  as  of  allied  forms,  yeasts, 
fungi,  and  protozoa,  not  to  mention  more  highly  organized  forms,  the  study 
of  which  is  comprised  loosely  in  the  term  bacteriology. 

Since,  not  only  do  we  find  that  a  large  number  of  diseases  are  directly 
due  to  the  action  of  micro-organisms,  but  the  principles  of  operative  technique 
depend  to  a  large  extent  on  a  proper  appreciation  of  the  knowledge  acquired 
in  the  study  of  these  simple  forms  of  life. 

Hence  a  short  account  of  this  science  forms  a  useful  introduction  to  a 
work  on  surgical  practice. 

The  larger  number  of  micro-organisms  of  surgical  import  belong  to  the 
group  of  Schizomycetes  or  Bacteria,  i.e.  organisms  which  reproduce  them- 
selves by  simple  division  or  fission,  but  other  minute  forms  of  life,  such 
as  the  amcebse,  causing  dysentery,  and  the  spirochete,  causing  syphilis,  are- 
second  to  none  in  importance.  The  diseases  due  to  yeasts  and  fungi  belong 
rather  to  the  provinces  of  general  medicine  and  dermatology  than  to  surgery 
proper. 

Bacteria  are  in  form  and  manners  of  the  simplest,  consisting  of  a  proto- 
plasmic body  devoid  of  nucleus,  but  sometimes  containing  granules  with 
various  staining  reactions  ;  at  times  surrounded  by  a  capsule  which  may 
require  skill  to  detect  or  be  sufficiently  obvious. 

Some  forms  possess  the  power  of  independent  motion  by  the  aid  of  a 
number  of  projections  called  Flagella,  only  discoverable  by  special  methods 
of  staining  and  corresponding  to  the  cilia  of  more  highly  organized  cells. 

Form.     In  this  respect  three  main  types  are  to  be  recognized  : 

(a)  Cocci  or  berry-like  forms,  which  may  be  round  (streptococci  and 
staphylococci),  ovoid  (pneumococci),  semicircular  (gonococci). 

(b)  Rod-like  forms  :   bacilli  (anthrax,  tubercle). 

(c)  Spirilla  or  curved  rods  :  the  comma  bacillus  of  cholera  is  the  best 
example  of  this  type,  since  there  is  a  tendency  to  class  most  of  the  spiral 
forms,  such  as  the  spirochete  of  syphilis,  with  protozoa,  because  in  their 
development  they  appear  to  undergo  other  phases  besides  that  of  rods,  which 
is  unusual  in  true  bacteria  or  schizomycetes. 

7 


\  TEXTBOOK  OF  SURGERY 

The  size  varies  iii  different  Bpecies  within  limits.     In  general  the  length 

of  a  bacillus  will  be  rather  less  than  the  diameter  of  a  red  corpuscle,  while 
its  diameter  will  be  about  one-tenth  part  of  the  diameter  of  a  red 
corpuscle. 

Reproduction.  This  will  take  place  when  there  is  a  good  supply  of 
food,  together  with  suitable  temperature  and  moisture,  and,  as  has  been 
mentioned,  takes  place  by  simple  division,  there  being  as  far  as  is  known 
no  conjugation  or  anything  of  a  sexual  nature  in  the  matter. 

The  plane  of  division  will  naturally  affect  the  mass  of  growth  or  "  colony," 
as  it  is  called,  arising  from  the  division  of  one  organism.  Thus  bacilli  divide 
at  right  angles  to  the  long  axis,  and  if  non-motile  tend  to  form  chains  of 
rods  curving  in  various  directions,  doubtless  from  the  varying  constitution 
of  the  medium  in  which  they  are  growing. 

Cocci  may  divide  in  a  similar  manner,  always  in  the  same  direction, 
producing  chains  of  progeny  (streptococci).  In  other  cases  after  division 
the  resulting  pairs  remain  together  for  a  while,  when  a  number  of  pairs 
or  "'diplococci"'  will  be  seen  on  microscopical  examination.  In  further 
divisions  the  original  members  in  some  way  become  separated,  so  that 
this  picture  is  constantly  maintained. 

Formation  of  diplococci  is  specially  noted  in  gonococci  and  pneumococci ; 
in  the  latter  case,  however,  there  is  a  tendency  for  two  or  more  pairs  to 
remain  in  close  apposition,  resulting  in  the  production  of  a  short  chain  of 
streptococcal  form.  When  division  occurs  in  more  than  one  plane,  broad 
and,  possibly,  deep  masses  of  cocci  will  result,  the  variety  met  with  in  our 
studies  being  the  staphylococcus,  so  called  from  the  fancied  resemblance 
of  the  mass  to  a  bunch  of  grapes. 

Spore  Formation.  When  the  conditions  of  existence  are  bad  (want  of 
food,  moisture,  improper  temperature,  &c.)  some  forms  are  capable  of 
resisting  extinction  by  taking  on  a  latent  form  of  existence  or,  so  to  speak, 
of  hybernating.  The  living  protoplasm  is  concentrated  into  part  of  the 
microbe  and  becomes  surrounded  by  a  thick  capsule,  the  whole  being  known 
as  a  spore.  This  process  of  sporulation  is  of  the  utmost  importance  to  the 
microbe  and  incidentally  to  the  surgeon,  since  spores  possess  extraordinary 
powers  of  vitality  and  can  resist  starvation,  drying,  even  boiling  and 
immersion  in  strong  antiseptics,  i.e.  bactericidal  drugs,  for  considerable 
periods,  while  non-sporing  organisms  succumb  very  speedily  to  such  rough 
treatment  :  when  the  adverse  fates  cease  to  trouble,  the  spore  again  develops 
into  the  complete  micro-organism. 

Comparatively  few  organisms  possess  the  power  of  forming  spores,  and 
all  such  arc  bacilli,  no  cocci  being  able  to  do  so.  The  bacilli  of  anthrax. 
tetanus  and  malignant  oedema  are  the  best-known  pathogenic  members 
of  this  group. 

Conditions  of  Life.  In  order  to  maintain  life  and  increase  in  numbers 
bacteria  require  wrater,  organically  combined  nitrogen  (e.g.  proteid),  certain 
salts,  and  a  suitable  temperature. 

Possessing  no  chlorophyl,  bacteria  cannot  make  use  of  inorganic  nitrogen, 


BACTERIA  9 

e.g.  salts  of  ammonia  or  nitrates,  to  build  up  their  protoplasm.  In  their 
mode  of  life  they  are  essentially  organized  ferments,  resembling  yeasts  and 
moulds  and  live  by  devouring  organic  matter,  which  they  break  down  into 
simpler  substances,  thus  obtaining  at  once  the  material  with  which  to  build 
their  own  bodies  and  the  energy  to  perform  their  functions. 

Distribution  and  Functions.  Bacteria  are  widely  spread  throughout 
the  surface  of  the  earth,  becoming  less  numerous  as  the  surface  is  left  in 
either  direction,  and  absent  in  high  altitudes,  as  on  snow  mountains,  or  in 
deep  excavations,  but  are  most  numerous  where  organic  life  is  congregated 
together,  since  there  will  be  the  greatest  collection  of  suitable  food. 

Bacteria  act  as  scavengers  or  middlemen  between  the  higher  animals 
and  plants,  breaking  up  the  complex  substances  produced  by  animal  life 
into  simple  ammonia  salts  and  nitrates,  &c,  suitable  for  the  digestions  of 
plants.  In  fact,  but  for  the  action  of  bacteria  the  world  would  be  cumbered 
with  dead  bodies  of  both  plants  and  animals. 

Microbes  then  must  not  be  regarded  as  synonymous  with  disease  ;  only 
about  thirty  species  out  of  hundreds  are  inimical  to  man  and  animals. 

The  rank  and  file  are  useful  servants  in  the  world's  economy  and,  harnessed 
by  the  ingenuity  of  man,  perform  important  and  difficult  tasks  in  arts  and 
trades  such  as  tanning,  the  manufacture  of  cheese,  linen,  indigo,  and  many 
others.  Water  is  essential  to  bacterial  growth,  in  some  cases  to  life.  Drying 
affects  different  organisms  to  a  varying  degree.  Tender  organisms,  as 
streptococci,  die  readily  if  dried,  while  others,  as  the  tubercle  and  glanders 
bacilli,  resist  drying  for  long  periods. 

The  optimum  temperature  varies  with  the  organism.  Most  pathogenic 
organisms  flourish  best  at  about  body  heat,  but  some  live  well  at  much 
lower  temperatures.  Freezing  inhibits  growth,  but  does  not  destroy  bacteria. 
Exposure  to  a  moist  heat  of  60°  C.  destroys  most  of  the  non-sporing  varieties 
in  a  short  time,  boiling  even  more  rapidly  ;  hence  the  value  of  boiling  and 
steaming  to  produce  aseptic  or  bacteria-free  conditions  for  operations,  &c. 
If  grown  at  a  temperature  above  the  optimum,  say  43°  C,  for  a  while,  the 
character  alters  and  a  pathogenic  organism  loses  much  of  its  virulence — a 
fact  which  is  the  basis  of  Pasteur's  method  of  inoculating  to  establish 
immunity  against  anthrax. 

Most  micro-organisms  live  with  or  without  the  presence  of  oxygen,  but 
some  only  grow  in  the  complete  absence  of  this  gas  :  such  organisms  are 
called  anaerobic,  amongst  which  are  those  of  tetanus,  malignant  oedenia, 
and  the  Bacillus  aerogenes  capsulatus.     Light  is  injurious  to  most  organisms. 

PRCDUCTS   OF   BACTERIA   AND   ALLIED   ORGANISMS 

In  their  growth-processes  and  in  breaking  down  complex  substances 
various  by-products  are  formed  by  bacteria,  differing  with  the  species  in 
question,  thus  :  Acids,  such  as  lactic,  butyric,  acetic.  Gases,  carbon  dioxide, 
sulphuretted  hydrogen,  marsh  gas.  &o.  Pigments,  such  as  the  blue  of 
Bacillus  Pyocyaneus,  the  red  of  Bacillus  Prodigiosus.  Aromatic  bodies, 
ludol,  skatol.  and  ethereal  matters  which  give  the  flavour  to  wines.   Ferments, 


In  A  TEXTBOOK  OF  SURGERY 

which  have  the  power  of  digesting  the  substance  on  which  the  organisms 
grow  :  for  instance,  staphylococcus  pyogenes  aureus  can  digest  and  liquefy 
gelatine,  and  the  same  liquefying  power  accounts  for  the  liquefaction  of 
tissues  resulting  in  the  formation  of  pus. 

Poisonous  substances,  the  constitution  of  which  is  little  known,  amongst 
which  are  ptomaines,  a  crystallizable  form  of  albuminoid  matter,  causing 
poisoning  when  ingested  in  the  form  of  putrid  meat,  &c.  Toxines,  whose 
constitution  has  not  been  determined,  but  are  apparently  albuminoid 
substances  varying  in  structure  and  potentialities  in  different  species  of 
micro-organisms  and  having  a  selective  action  on  the  cells  of  the  infected 
animal.  Thus  the  toxines  of  pyogenic  organisms  act  on  any  tissue,  causing 
the  cells  to  swell  and  undergo  the  changes  known  as  cloudy  swelling,  while 
exudation  of  lymph  and  leucocytes  into  the  tissue-spaces  results  in  cedema, 
and  the  upsetting  of  the  heat-regulating  mechanism  causes  fever. 

The  toxines  of  tetanus  and  some  of  those  of  diphtheria  act  on  the  nerve 
cells,  producing  spasm  or  paralysis  of  the  muscles  supplied  by  these  cells. 
Some  toxines  are  diffused  out  into  the  body  of  the  infected  animals,  e.g. 
tetanus,  without  invasion  by  bacteria  (exo-toxines)  ;  others,  e.g.  those  of 
the  tubercle  bacillus,  remain  mostly  in  the  body  of  the  microbe  and  diffuse 
out  after  the  death  of  the  infecting  microbe  and  destruction  of  its  capsule 
(endo-toxines). 

METHODS   OF  INVESTIGATING   BACTERIA 

These  are  microscopical,  cultural,  by  inoculation,  and  by  the  reaction 
of  the  infected  patient's  serum  to  organisms  or  their  products  (serum 
reactions). 

(a)  Fresh  living  bacteria  can  be  examined  microscopically  in  the  fluid 
where  they  exist.  Little  can  thus  be  determined,  except  their  presence, 
shape,  and  motility. 

(b)  By  drying  a  thin  film  of  material  containing  bacteria  and  staining 
with  various  aniline  dyes  some  more  definite  knowledge  is  obtainable,  since 
the  affinity  of  bacteria  for  certain  dyes  and  the  firmness  or  looseness  with 
which  they  retain  these  colouring-matters  under  the  action  of  decolorizing 
agents  implies  a  difference  in  constitution.  These  different  reactions  to 
staining  agents  have  led  not  only  to  methods  of  distinguishing  different  species, 
but  also  to  advances  in  plans  for  attacking  them  with  suitably  combined 
drugs,  so  well  exemplified  by  the  researches  of  Ehrlich  in  the  diseases  due 
to  spirilla  and  other  protozoa. 

Usually  in  addition  to  a  dye  some  mordant  is  necessary  to  produce 
satisfactory  staining,  such  as  carbolic  acid  or  an  alkali.  Such  mordanted 
stains  as  carbol-fuchsin,  Loefler's  methylene-blue,  and  carbol-thionin  will 
stain  most  bacteria,  but  demonstrate  little  more  than  the  presence  and 
shape  of  the  organisms. 

.More  is  learnt  by  using  decolorizing  agents  after  staining,  the  most 
generally  used  methods  being  those  of  Gram  and  Ziehl-Nielsen. 

In  the  former,  after  staining  with  alcoholic  solution  of  gentian  violet, 


INVESTIGATION  OF  BACTERIA  11 

reinforced  with  carbolic  acid  or  aniline  as  a  mordant,  the  film  is  placed  in 
iodine  solution,  and  this  is  washed  out  with  alcohol.  Certain  organisms 
after  this  treatment  retain  the  stain  and  are  called  Gram-positive  ;  others 
are  decolorized  and  are  called  Gram-negative.  In  the  former  group  are 
pyogenic  staphylococci  and  streptococci,  pneumococci,  tetanus,  anthrax, 
diphtheria,  and  actinomycosis  bacilli.  The  Gram-negative  organisms  are 
gonococci,  colon,  typhoid,  and  glanders  bacilli,  &c. 

In  the  Ziehl-Nielsen  process  the  films  are  stained  with  boiling  carbol- 
fuchsin  for  a  few  minutes  and  decolorized  with  25  per  cent,  sulphuric  acid. 
If  this  treatment  is  followed  by  washing  with  alcohol,  only  the  tubercle 
bacillus  and  that  of  leprosy  retain  the  fuchsin  (red).  The  smegma  bacillus 
retains  the  stain  after  washing  with  acid,  but  loses  it  after  subsequent 
decolorizing  with  alcohol.  The  terms  acid-  or  alcohol-fast  are  applied 
to  these  organisms. 

CULTURAL  METHODS 

These  are  used  partly  to  observe  the  method  of  growth  which  varies 
in  abundance  and  quality  in  different  species,  and,  secondly,  to  obtain  Pure 
Cultures. 

The  cultivation  method  is  of  great  value  for  study  of  the  manner  of 
growth  and  reaction  of  organisms  to  reagents,  including  production  of  acids, 
curdling  of  milk,  formation  of  gas,  and  lastly,  extracting  the  toxins  from 
masses  of  dead  bacteria,  or  making  vaccines  from  them,  which  is  useful  in 
the  diagnosis,  prophylaxis,  and  treatment  of  certain  infective  diseases. 

Various  media  are  used  for  the  cultivation  of  bacteria  :  solid,  as  gelatin. 
agar,  inspissated  blood  serum ;  or  liquid,  as  broth  and  milk,  to  which  may 
be  added  colouring  reagents  to  detect  acids,  sugar  to  test  powers  of  fermenta- 
tion, by  which  means  various  different  types  of  (as  far  as  the  microscopical 
appearances  go)  apparently  the  same  organism  are  to  be  made  out. 

Pure  cultures  are  obtained  by  repeated  dilutions  of  fluid  containing 
bacteria  and  making  Plate  Cultures  from  these. 

A  bulk  of  melted  gelatine  or  agar  is  inoculated  with  a  minute  mass  of 
bacteria  or  substance  containing  a  mixture  of  these  and  well  mixed  ;  a 
minute  fraction  of  the  diluted  mass  of  bacteria  is  taken,  and  another  mass 
of  liquid  gelatine  inoculated  :  this  is  repeated  four  or  five  times.  Each 
mass  of  gelatine  containing  various  dilutions  of  bacteria  is  poured  into  a 
sterile  capsule  which  is  covered,  allowed  to  cool  and  solidify,  and  is 
then  incubated.  In  the  capsule  where  the  dilution  is  suitable  single  bacteria 
will  be  scattered  throughout,  widely  enough  separated  for  the  colonies 
arising  from  individual  bacteria  to  be  recognized.  Noting  the  differences 
in  their  growth-characteristics  they  can  then  be  examined  microscopicallv 
and  transferred  to  a  fresh  tube  of  medium,  where  they  will  continue  to  grow 
in  pure  culture.  In  other  words,  a  pure  culture  consists  of  the  lineal 
descendants  of  a  single  organism. 

Another  method  of  producing  pure  cultures  is  by  inoculation  into 
susceptible  animals.     This  method  is  suitable  with  slowly  growing  organisms 


12  A  TEXTBOOK  OF  SURGERY 

as  the  tubercle  bacillus,  which,  if  grown  in  the  ordinary  way  on  media,  will 

on  1"'  over-grown  by  other  more  rapidly  growing  forms  as  to  render 
production  of  pure  culture  by  this  method  impossible.     Thus  if  a  suppurative 

lesion  he  suspected  of  owing  its  causation  to  tubercle  bacilli,  but  these 
cannot  be  found  from  their  smallness  in  numbers,  as  is  often  the  case,  some 
of  the  pus  may  be  injected  into  the  peritoneum  of  a  guinea-pig,  where 
tubercles  will  develop  in  a  few  weeks. 

Investigation  by  means  of  Serum  Reactions  will  be  referred  to  later  under 
Immunity. 

PATHOGENIC   ORGANISMS— INFECTIONS 

As  has  already  been  noted,  most  micro-organisms  are  capable  of  living 
only  on  dead  organic  matter,  in  which  they  produce  the  processes  known 
as  decay,  putrefaction,  ripening  of  cheese  and  game,  formation  of  alcohol 
from  sugar  or  vinegar  from  alcohol,  &c. 

Such  organisms  are  known  as  saprophytes,  i.e.  producers  of  decay,  or 
those  who  live  on  decaying  materials. 

Comparatively  few7  have  the  power  of  existing  in  living  animals  and 
producing  pathological  changes  in  the  tissues  of  their  host.  These  are 
described  as  parasites,  infective  or  pathogenic  organisms. 

The  two  latter  terms  are  most  suitable,  since  the  term  parasite  is  also 
applied  to  denizens  of  the  superficial  layers  of  the  skin  or  surfaces  of  internal 
viscera,  such  as  the  intestine.  Many  of  the  latter  (sometimes  called  entozoa) 
can  hardly  be  regarded  as  pathogenic,  but  merely  as  harmless  strangers 
within  the  gates.  In  some  instances,  however,  these  strangers  may  become 
pathogenic  and  damage  or  destroy  their  host ;  the  colon  bacillus  is  of  specially 
evil  repute  in  this  respect. 

A  distinction  is  drawn  between  organisms  which  can  only  exist  as 
parasites,  which  are  called  Obligatory  parasites,  such  as  the  spirochete  of 
syphilis,  the  gonococcus,  the  bacillus  of  leprosy,  on  the  one  hand,  and 
others  which  can  live  readily  as  saprophytes,  but  may  on  occasion  take 
on  a  parasitic  and  pathogenic  existence,  of  which  anthrax,  typhoid,  tetanus 
bacilli,  and  the  pyogenic  cocci  are  well-known  instances.  These  arc  known 
as  Facultative  parasites.  All  parasites  living  in  the  tissues  and  not  merely 
on  the  surface  of  the  skin  or  lining  of  viscera  are  pathogenic,  since  if 
unable  To  produce  pathogenic  effects  they  will  soon  be  destroyed  by  the 
tissues. 

Infection  then  implies  the  entrance  of  pathogenic  organisms  into  the 
body,  where  they  are  able  to  live  and  produce  definite  diseases. 

Proof  of  Infection.  Absolute  proof  of  the  cause  of  an  infective  disease 
demands  the  fulfilment  of  the  following  "postulates"  stated  by  Koch, 
which  may  be  regarded  as  the  canon  of  pathological  bacteriology. 

(1)  A  definite  organism  (recognized  by  microscopic  and  cultural  tests) 
musl  be  present  in  the  body  in  all  cases  of  the  disease. 

(2)  It  must  be  possible  to  grow  this  organism  in  pure  culture  for  several 
generations  (to  eliminate  the  remains  of  serum,  &c,  obtained  from  the 


INFECTIONS  13 

original  host,   which  might  be  suspected  of  containing  the  virus  of  the 
disease). 

(3)  Inoculations  with  such  pure  cultures  must  cause  again  the  original 
disease  in  susceptible  animals. 

(4)  The  organism  must  be  recovered  again  from  such  an  infected 
animal. 

Where  it  is  not  possible  to  grow  a  parasite  on  culture  media,  e.g.  the 
leprosy  bacillus,  such  tests  are,  of  course,  inapplicable,  but  other  methods 
may  render  the  identification  of  pathogenic  organisms  practically  certain, 
such  as  agglutination  or  destruction  of  bacteria  by  the  serum  of  infected 
patients. 

The  identification  of  infective  agents  has  been  a  matter  of  time  and 
enormous  and  ingenious  research  ;  comparatively  trifling  factors  rendering 
their  recognition  difficult.  Thus  the  tetanus  bacillus  being  anaerobic  and 
only  needing  to  occur  in  relatively  small  numbers  in  a  wound  to  produce 
its  toxic  effects,  was  only  discovered  comparatively  late  ;  the  difficulty  of 
staining  the  tubercle  bacillus,  till  the  patient  work  of  Koch  rendered  this 
possible,  is  another  example  of  the  difficulties  involved. 

Doubtless  with  further  research  the  causes,  at  present  unknown,  of 
diseases  which  must  on  other  grounds  be  regarded  as  infective,  will  be  made 
clear. 

Varieties  of  Infection.  Infections  may  be  localized  in  one  part  of  the 
body  or  generalized  throughout  the  tissues  and  organs  ;  in  this  respect 
various  infective  organisms  behave  differently. 

(a)  In  a  few  instances  infection  is  completely  local,  a  general  spread  of 
organisms  being  practically  unknown,  and  the  general  effects,  i.e.  the 
disease,  are  produced  by  the  action  of  exo-toxines  which  diffuse  from  the 
parasites  into  the  system  of  the  host.  The  best  examples  of  such  infections 
are  tetanus  and  diphtheria.  In  these  diseases  the  organisms  are  situated 
on  some  rawed  area  of  the  body,  which  has  been  caused  by  injury  or  infection 
with  other  organisms  and  so  denuded  of  the  protective  epithelium,  thus 
allowing  percolation  of  the  poisons  of  the  parasite,  very  much  as  from  a 
poisoned  weapon. 

(b)  More  commonly  in  surgical  cases  the  infection  is  localized,  but  may 
spread  through  the  body  by  the  passage  of  organisms  along  the  blood  and 
lymph  vessels  and  other  body  spaces,  e.g.  the  peritoneum. 

Such  spread  is  due  to  an  excessive  virulence  of  the  infection  or  a  poor- 
resistance  of  the  body  infected.  In  this  class  are  included  the  pyogenic 
organisms,  the  gonococcus,  the  pneumococcus,  tubercle,  glanders,  anthrax, 
colon,  bacilli.  &c. 

(e)  In  the  third  group,  if  infection  is  to  occur  at  all,  it  must  be  general, 
local  infection  being  unknown  :  such  are  the  exanthemata,  typhoid  fever, 
plague.  &c. 

Syphilis  should  also  be  regarded  as  belonging  to  this  group,  for  although 
the  initial  hard  chancre  appears  to  be  a  local  lesion,  this  does  not  become 
manifest  till  there  is  dissemination  of  organisms  throughout  the  body.     As 


ll  A  TEXTBOOK  OF  SURGERY 

will  be  soon  later,  with  the  exception  of  syphilis,  mosl  infections  in  surgical 
practice  belong  to  the  firsl  two  groups. 

The  preceding  remarks  bring  us  to  a  consideration  of  Virulence  and 
Attenuation,  tonus  applied  to  varying  powers  <>f  producing  pathogenic 
conditions,  possessed  by  the  same  <\nso  (numerically)  of  any  given  infective 
organism. 

The  powers  of  infection,  spreading,  and  general  pathogenicity  of 
organisms  differs  greatly  with  changes  in  their  mode  of  life. 

The  virulence  of  organisms  is  increased  by  suitable  conditions.  Thus 
if  a  series  of  animals  be  inoculated  one  from  another  with  an  infective 
organism,  the  infection  becomes  exalted  in  virulence,  and  death  can  be 
produced  by  a  smaller  dose  of  the  infection,  i.e.  inoculation  with  a -smaller 
number  of  organisms  ;  or  an  organism  which  can  only  naturally  produce 
a  local  infection  may.  if  exalted  in  virulence,  be  capable  of  causing  a  general 
infection.  Clinically,  the  virulence  of  streptococci  is  raised  when  growing 
in  the  peritoneum  and  causing  streptococcal  peritonitis ;  fatal  cases  of 
septicaemia  following  infection  of  the  hands  of  surgeons  through  needle 
pricks  while  operating  on  such  cases  are  well  known. 

Other  conditions  may  diminish  virulence  or  produce  attenuation,  e.g. 
the  anthrax  bacillus  grown  at  a  temperature  of  42°  C.  loses  much  of  its 
power  of  producing  disease. 

SAPR^MIA— SEPTICAEMIA— BACILL^MIA 

When  an  infection  becomes  generalized  the  bacteria  in  question  can 
often  be  discovered  in  the  blood  by  withdrawing  10  c.c.  from  a  vein,  with 
aseptic  precautions,  and  inoculating  culture  media  therewith.  Such  a 
condition  is  described  as  Septicaemia  or,  better,  Bacillaemia  (the  term  septi- 
caemia being  a  clinical  term  of  some  standing),  and,  although  bacteria  must 
have  passed  through  the  blood,  it  is  often  impossible  to  demonstrate  them 
at  any  given  moment. 

The  term  Sapraemia  is  used  to  denote  that  there  are  circulating  in  the 
blood  toxins  derived  from  bacteria  situated  outside  the  body  tissues,  as  in 
the  sloughs  of  an  unclean  wound  or  in  the  decomposing  clots  in  the  uterus, 
where  asepsis  has  not  been  maintained  :  such  bacteria  being  not  definitely 
infective  or  able  to  grow  in  living  tissues,  but  producing  deleterious,  absorb- 
able substances.  Little  is  known  of  these  toxines,  and  many  cases  regarded 
as  sapraemia  are  really  cases  of  mild  septicaemia  or  bacillaemia.  For  although 
tin;  worst  grades  of  this  condition  are  usually  fatal  it  is  recognized  that 
all  manner  of  milder  varieties  are  found  in  many  of  which  recovery  is  possible, 
and  in  which  constitutional  effects  may  not  even  be  severe  though  bacteria 
are  present  in  the  blood. 

It  must  also  be  recognized  that  infective  organisms  may  pass  through 
the  blood  and  tissues  rapidly  without  producing  pathological  changes. 
Thus  the  tubercle  bacillus  is  found  in  enlarged  tonsils  without  signs  of  the 
characteristic  lesions  produced  by  this  organism,  although  the  lymphatic 
glands  into  which  the  tonsillar  lymphatics  drain  may  be  in  a  state  of  definite 


IMMUNITY  15 

tuberculosis  ;  again  tubercle  bacilli  may  be  secreted  in  the  urine  and  thus 
pass  through  a  kidney  which  is  not  infected  with  tuberculosis.  The  fact 
that  the  tubercle  bacillus  is  a  slowly  acting  organism  and  if  passed  along 
quickly  has  no  time  to  produce  its  effects  will  no  doubt  explain  these 
anomalies. 

ACTION  OF  PATHOGENIC  BACTERIA  ON  THE  TISSUES 
Varying  results  follow  infection  with  diverse  micro-organisms.  In 
the  larger  number  of  cases  the  changes  are  those  of  inflammation  with 
its  various  incidents  and  sequelae,  both  local  and  general,  viz.  hyperaemia, 
exudation  of  fluid  (oedema)  and  cells,  local  or  general ;  cell  changes  as  cloud  v 
swelling,  fatty,  and  other  degenerations  ;  multiplication  of  connective  • 
tissue  cells  and  consecutive  fibrosis  ;  pyrexia,  leucocytosis,  constitutional 
depression,  &c,  all  of  varying  degrees  of  acuteness  or  chronicity.  In  other 
examples  specific,  selective  action  occurs  as  in  the  irritation  of  the  cells 
of  the  central  nervous  system  in  tetanus  or  paralysis  of  similar  origin  in 
diphtheria. 

REACTION   OF  THE   TISSUES   TO   INFECTIVE  BACTERIA 

In  the  last  section  some  of  the  reactionary  measures  of  the  tissues  have 
been  mentioned,  since  inflammation  is  the  response  of  the  organism  to 
infective  stimulus  and  is  to  a  certain  degree  protective. 

The  exudation  of  leucocytes  and  other  tissue  cells  and  the  formation 
of  fibrous  tissue  will  devour  and  destroy  micro-organisms  by  the  process 
known  as  phagocytosis,  or  enmesh  the  infecting  agent  and  render  it  innocuous 
till  the  damaged  area  is  converted  into  fibrous  tissue  or  becomes  calcified, 
or  bursts  on  the  surface  as  an  abscess,  discharging  the  infective  material 
in  the  form  of  pus. 

In  addition  to  these  gross  changes  other  more  subtle  mod?s  of  protection 
are  developed  which  are  included  under  the  term  Immunity. 

IMMUNITY  AND  DEFENCE  AGAINST  PATHOGENIC  BACTERIA 

While  the  above-mentioned  changes  of  inflammatory  type  may  be 
regarded  as  the  local  defence  against  microbic  invasion,  there  exists  in 
addition  an  equally  or  even  more  important  mechanism  in  the  tissue  juices 
which  confers  the  property  of  immunity  to  the  subject. 

Natural  Immunity.  The  mere  fact  that  we  are  eating,  breathing,  and 
generally  wallowing  in  bacteria  throughout  our  lives,  implies  that  there 
is  a  natural  immunity  against  most  organisms,  which  is  the  same  thing  as 
calling  them  non-pathogenic.  This  becomes  more  striking  when  we  consider 
that  certain  organisms  are  harmless  to  some  species  of  animals  while  patho- 
genic to  others.  The  first  class  are  said  to  be  Naturally  immune,  the  latter 
Susceptible  ;  thus  white  rats,  Algerian  sheep,  and  carnivorous  animals  are 
immune  to  anthrax  infection,  while  in  cattle  infection  with  these  bacilli 
rapidly  leads  to  a  general  septicaemia  or  blood  infection.  The  human  race 
occupies  an  intermediate  position  with  regard  to  this  disease.    Infection  with 


16  A  TEXTBOOK  OF  SURGERY 

anthrax  is  generally  Local  and  may  remain  so,  the  lesion  healing  naturally  : 
or  the  infection  may  spread,  leading  to  fatal  septicaemia.  Thus  while  white 
rats  and  the  carnivora  are  said  to  possess  complete  natural  immunity  to 
anthrax,  human  beings  are  partially  immune,  and  cattle  completely  suscep- 
tible. In  the  same  race  immunity  differs  in  different  individuals;  thus  some 
persons  seem  to  he  incapable  of  catching  scarlet  fever,  mumps,  &c.,  in 
spite  of  frequent  exposure  to  infection. 

Relative  immunity  is  altered  in  the  same  individual  by  circumstances 
about  which  our  knowledge  is  small,  since  often  the  most  robust  in  appear- 
ance  readily  become  infected  with  diseases  of  bacterial  origin.  Still  there 
semis  little  doubt  that  general  depression  of  bodily  powers,  as  by  starvation, 
cold,  exposure,  and  various  systemic  diseases,  as  diabetes,  chronic  nephritis, 
and  other  causes  of  malnutrition,  predisposes  greatly  to  infection,  or,  in 
other  words,  diminishes  immunity. 

A  more  important  form  of  immunity  from  a  therapeutic  standpoint  is 
known  as  Acquired  immunity,  which  arises  in  subjects  normally  prone  to 
infections,  since  much  curative  and  prophylactic  medicine  depends  on  a 
knowledge  of  this  subject. 

It  has  long  been  known  that  a  second  attack  of  certain  infective  diseases 
is  extremely  rare,  and  it  is  said  that  such  diseases  "  protect  "  against  further 
attacks. 

The  discovery  of  Jenner  that  inoculation  (vaccination)  with  what  is 
probably  an  attenuated  form  of  smallpox,  derived  from  cows,  protects  against 
smallpox.  A  further  step  in  this  subject,  based  on  the  memorable  researches 
of  Pasteur,  was  the  discovery  that  protection  could  be  obtained  against 
inoculation  with  a  fatal  dose  of  micro-organisms  by  preliminary  inoculation 
with  cultures  of  dead  bacteria  of  the  same  species  or  even  with  living  cultures 
the  virulence  of  which  had  been  diminished  by  growth  under  unfavourable 
conditions.  Further,  it  has  been  found  that  the  serum  of  such  "  immunized  " 
animals,  if  injected  into  other  animals,  renders  the  latter  immune  against 
attacks  of  the  disease  in  question,  or  may  in  some  circumstances  cure  such 
disease  if  already  present. 

Where  the  immunity  has  been  acquired  by  inoculation  with  an  attenuated 
virus  of  the  disease  the  condition  is  described  as  Active  immunity  :  when 
due  to  injection  of  serum  from  an  animal  immunized  in  this  manner,  Passive 
immunity  is  the  term  employed.  In  either  case  immunity  is  due  to  certain 
bodies  present  in  the  blood  and  tissue — juices  described  as  alexins,  lysins, 
opsonins,  agglutinins,  or  more  generally  as  '•  hormones,"  which  embrace  all 
the  other  classes.  Thus  the  serum  of  patients  suffering  with  infective 
disease,  when  added  to  an  emulsion  of  the  bacteria  causing  the  condition, 
forces  the  latter  to  become  massed  into  clumps  or  "  agglutinated  "  ;  in  other 
cases  destruction  of  bacteria  is  produced  by  such  sera  from  the  action  of 
•■  lysins."  The  method  in  which  these  anti-bodies  are  produced  is  uncertain. 
Possibly  they  are  produced  by  blood  cells,  especially  polymorphonuclear 
leucocytes,  which  increase  in  numbers  in  the  blood  in  many  infective  diseases 
(leucocytosis).     This,  of  course,  suggests  that  the  bone  marrow  where  these 


VACCINES  17 

cells  are  formed  is  the  place  of  formation  of  hormones  or  "  anti-bodies,""  as 
they  are  sometimes  called.  That  such  bodies  exist,  and  in  several  forms 
has  been  settled  with  tolerable  certainty  by  bacteriological  research,  and 
a  considerable  amount  of  success  has  followed  this  line  of  investigation 
both  in  the  diagnosis  and  treatment  of  infective  disease,  although  there 
still  remains  much  to  be  learned  in  this  branch  of  medical  research. 

With  regard  to  diagnosis,  the  power  of  the  serum  of  an  infected  animal 
to  dissolve  the  bodies  of  the  infecting  species  of  bacteria  (when  mixed  with 
an  emulsion  of  the  latter)  or  cause  them  to  form  clumps,  constitutes  a  specific 
reaction  for  the  organisms  of  the  disease  in  question.  In  a  similar  manner 
"  fixation  "  or  "  deviation  "  of  the  complement  (which  is  a  part  of  the 
protective  mechanism  in  the  serum)  in  Wasserman's  reaction  is  of  great 
importance  in  the  diagnosis  of  lesions  due  to  the  spirochete  of  syphilis 
and  will  be  considered  later. 

The  power  of  leucocytes  to  ingest  and  destroy  bacteria  (which  has  been 
so  thoroughly  elaborated  by  Metschnikoff  in  his  theory  of  Phagocytosis, 
and  which  appears  to  be  altered  by  the  action  of  the"  serum  of  infected 
animals,  with  respect  to  the  organism  causing  the  infection)  is  the  basis 
on  which  was  raised  the  method  of  finding  the  opsonic  index  (Wright). 
This  method  is  now  regarded  as  largely  fallacious,  though  the  work  on 
Vaccine  Treatment  based  on  this  method  still  holds  ground  and  is  of  service 
in  the  treatment  of  certain  infections. 

In  the  direction  of  treatment  the  formation  of  anti-bodies  is  used  in 
two  ways,  producing  : 

(1)  Active  immunity,  from  inoculation  with  cultures  of  bacteria. 

(2)  Passive  immunity  from  the  injection  of  anti-sera,  which  are  made 
by  the  action  of  bacteria  or  their  products  injected  into  some  other  animal 
whose  serum  then  constitutes  the  anti-serum. 

(1)  Vaccine  Therapy.  The  principle  involved  is  that  of  increasing  the 
resistance  of  a  patient  by  inoculation  with  small  doses  of  cultures  (usually 
killed  by  heating)  of  the  organism  producing  the  disease  from  which  he 
suffers.  Such  inoculation,  if  given  in  suitable  doses,  increases  the  pro- 
duction of  anti-bodies,  bactericidal,  antitoxic,  &c,  without  rendering 
the  condition  of  disease  worse.  In  the  more  chronic  forms  of  infection, 
due  to  pyogenic  cocci,  the  colon  bacillus,  &c,  vaccine  treatment  is  often 
successful ;  but,  since  the  opsonic  index  is  unreliable,  it  is  not  easy  to 
gauge  the  suitability  of  cases  for  this  treatment  nor  to  be  certain  that  the 
results  are  due  to  the  treatment.  In  tuberculosis  especially  results  are 
uncertain ;  there  can  be  little  doubt  that  good  results  from  vaccine 
therapy  do  result,  but  in  other  cases  the  condition  is  made  worse,  and 
we  have  at  present  no  method  of  deciding  beforehand  which  cases  are 
suitable  for  this  treatment. 

(2)  Passive  immunity  is  produced  by  the  use  of  anti-sera  obtained  by 
inoculating  suitab'e  animals  with  the  bacilli  in  question  or  their  toxines. 
Such  sera  may  be  anti-toxic  or  anti-microbic,  i.e.  neutralizing  the  toxines 
or  destroying  the  bacteria,  or  may  combine  the  two  functions. 


18  A  TEXTBOOK  OF  SURGERY 

Antitoxic  Sera.  These  are  naturally  suitable  in  those  infections  where 
the  infecting  agent  does  not  invade  the  body  to  any  great  extent,  but  its 
toxins  diffuse  through  the  system  producing  the  disease.  Tetanus  and 
diphtheria  are  the  best  examples  of  this  variety.  'I  he  antitoxic  serum  is 
produced  by  injecting  increasingly  large  doses  of  the  toxins  into  animals 
(horses  and  asses  are  often  employed).  The  blood  of  these  animals  is  later 
drawn  off.  the  serum  separated  and  stored  with  aseptic  precautions. 

The  results  from  the  use  of  such  anti-serum  in  the  case  of  diphtheria 
are  admirable,  since  the  disease  can  be  diagnosed  early  and  anti-serum  given 
before  the  toxins  are  formed  in  large  quantities  and  become  firmly  attached 
to  the  molecules  of  the  cell  protoplasm.  The  results  in  cases  of  tetanus 
are  disappointing,  for  the  disease  is  never  diagnosed  till  the  nervous  system 
is  invaded,  and  by  this  time  the  toxins  have  firmly  combined  with  the  cells, 
and  the  antitoxin  cannot  turn  them  out  of  its  combination  and  neutralize 
it.  Consequently  the  disease  advances.  For  it  appears  that  toxins 
and  antitoxins  combine  and  neutralize  each  other  just  as  do  acids  and 
alkalis  ;  further,  such  neutralization  can  be  performed  in  vitro  perfectly 
well.  Xow  if  the  toxin  has,  so  to  speak,  a  start  of  the  antitoxin  in  the 
system,  it  will  combine  with  cells  for  which  it  has  a  selective  affinity  (cells 
of  the  central  nervous  system  in  the  case  of  tetanus),  and  having  thus 
combined  can  hardly  be  removed  again.  The  practical  outcome  of  this 
is  to  insist  on  the  earliest  possible  use  of  antitoxins,  where  indicated  for 
disease. 

Anti -bacterial  sera  probably  act  as  much  against  the  toxins  as  the  bodies 
of  bacteria,  and  have  been  made  against  streptococci  and  anthrax.  In 
the  latter  case  serum  treatment  is  very  useful ;  in  the  former  often  disap- 
pointing, possibly  because  there  are  many  varieties  of  streptococci,  and  the 
particular  variety  represented  in  the  serum  may  not  be  the  one  causing  the 
disease.  For  this  reason  ' ;  polyvalent "  serum  is  employed,  produced  by 
inoculation  with  several  varieties  of  the  organism. 

These  matters  will  be  further  discussed  under  special  infections. 


CHAPTER  III 
INFLAMMATION  AND   REPAIR 

General  Considerations  :  Simple  Inflammation  :  Healing  :  Varieties  :  Com- 
plications and  Sequelae  of  Inflammation  :  Course  and  Termination  of 
Inflammation  :  Acute.  Subacute,   and  Chronic  Inflammation  :  Diagnosis  : 

Treatment. 

The  modern  conception  of  the  term  inflammation  may  be  shortly  stated 
as  "  the  response  of  tissues  to  injury,  which  is  insufficient  to  destroy 
them." 

By  injuries  are  meant  such  different  insults  as  blows,  cuts,  crushes, 
burns,  electrical  discharges,  caustics  and  other  poisons,  among  which  not 
the  least  important  are  those  produced  by  pathogenic  organisms.  Since 
the  response  of  tissues  naturally  aims  at  salvation,  it  follows  that  repair 
or  the  process  of  healing  forms  an  important  part  of  inflammation. 

As,  however,  in  a  large  proportion  of  cases  the  severity  of  the  injury 
either  (a)  passes  beyond  the  vital  power  of  the  tissues,  or  (b)  continues  to 
act  till  their  resistance  is  overcome,  it  results  that  destruction  of  tissue 
often  takes  place  in  inflammatory  conditions,  and  we  find  that  degenerations, 
necroses,  suppurations,  ulcerations,  gangrene,  &c,  are  closely  associated 
with  inflammation,  though  not  due  to  the  inflammation,  since  this  is  an 
attempt  on  the  part  of  the  tissues  of  the  injured  organism  to  prevent  such 
more  grave  terminations. 

The  classic  description  of  inflammation  considered  rather  the  condition 
present  than  the  purposive  reaction  of  the  tissues,  and  the  criteria  of 
inflammation,  in  the  classic  sense,  can  only  be  applied  to  gross  macroscopic 
conditions  of  this  nature.  Finer  changes  of  the  same  nature,  so  slight  as 
to  escape  the  keenest  eye  or  the  most  sensitive  finger,  are  the  underlying 
phenomena  of  healing  or  repair,  which  have  been  revealed  by  microscopic 
research. 

Heat,  redness,  swelling,  pain,  and  impaired  function  are  only  the  outward 
signs  of  inflammation  and  often  only  present  when  the  damage  to  the  tissues 
is  of  such  a  degree  that  complete  recovery  is  no  longer  possible.  Such  a 
degree  of  inflammation  is  likely  to  be  followed  by  necrosis,  suppuration, 
and  such-like  evidence  of  failure  on  the  part  of  the  inflammatory  reaction 
to  cope  with  the  injury,  leading  to  the  belief  that  inflammation  is  a  baneful 
proceeding.  We  must  at  the  outset  clearly  distinguish  between  inflamma- 
tion and  the  Causes  of  inflammation,  the  latter  of  which  are  the  object  of 
remedial  attack  in  a  large  majority  of  cases. 

19 


20  •      A  TEXTBOOK  OF  SURGERY 

EXAMPLE   OF   SIMPLE   INFLAMMATION— WOUND  HEALING 

The  healing  of  an  aseptic  wound  of  t  he  peritoneum  forms  a  good  example 
of  inflammation  pure  and  simple,  since  the  injury  has  practically  destroyed 

DO  tissue  and  the  whole  proceeding  is  essentially  one  of  repair. 

We  will  assume  that  the  wound  is  sutured  bo  that  the  divided  surfaces 
are  in  proper  apposition,  and  the  suture  material  is  aseptic  and  but  slightly 
irritating.  The  vessels  divided  at  the  edge  of  the  wound  are  soon  sealed 
with  blood  clot  and  lymph,  the  cut  surfaces  cease  to  ooze  and  are 
merely  moist.  Shortly  there  is  a  dilatation  of  the  vessels  surrounding  the 
injured  area,  but  in  such  an  example  of  slight  degree,  and  only  extending 
a  short  distance  from  the  edge  of  the  wound.  Next  there  is  an  exudation 
of  plasma  through  the  walls  of  the  blood  and  lymph  vessels,  and  in  the 
plasma  are  extided  also  leucocytes  of  the  polymorphonuclear  type  as  well 
as  other  cells,  including  red  corpuscles,  though  the  latter  are  seldom  in  any 
quantity  in  simple  inflammation.  This  exudate,  which  clots  readily,  passes 
into  the  injured  tissue,  between  the  cut  edges  of  the  wound  and  on  the 
surface  of  the  peritoneum  around  ;  and  the  consequence  of  this  outpouring 
is  that  in  a  few  hours  the  wound  is  filled  and  covered  over  with  a  plastic 
material  usually  called  "  lymph,"  consisting  of  coagulated  plasma,  contain- 
ing cells  of  various  sorts.  This  coagulated  lymph  forms  the  initial  bond 
of  union  between  the  surfaces  of  the  wound  and  temporarily  glues  them 
together. 

The  hypersemia  from  vaso-dilatation  accounts  for  the  redness  ;  this, 
in  addition  to  the  exudation,  causes  swelling  of  the  part ;  of  the  other  clas- 
sical signs,  heat  will  be  associated  with  hyperaemia,  but  will  only  be  distin- 
guishable in  superficial  parts.  This  local  increase  of  heat  is  simply  due 
to  more  warm  blood  being  brought  to  the  part  and  not  to  any  ascertainable 
increase  in  the  local  production  of  heat.  Pain  and  loss  of  function  will 
also  be  present  to  a  slight  degree  ;  the  former  due  to  the  pressure  on  nerves 
by  the  exudation,  the  latter  resulting  from  the  pain  and  swelling. 

All  these  classical  signs,  in  a  wound  healing  aseptically.  will  be  minimal 
and  of  little  more  than  microscopic  amount.  If,  however,  the  natural 
mild  course  of  inflammatory  repair  is  interfered  with,  as,  for  example,  by 
the  invasion  of  pathogenic  bacteria,  the  signs  will  be  more  marked  and 
obvious  to  the  unaided  senses.  So  far  the  changes  described  have  been 
entirely  confined  to  the  vessels  and  their  contents,  but  in  addition  changes 
occur  in  the  tissues  themselves.  The  branching  cells  of  the  connective 
tissue,  which  forms  the  basis  of  most  tissues,  and  in  the  present  example 
(peritoneum)  practically  the  whole  tissue,  become  altered.  The  branches 
retract,  the  cells  becoming  rounded  and  undergoing  division  ;  the  cells 
also  acquire  locomotor  power,  migrating  into  the  already  described  mass 
of  lymph  and  exuded  blood  cells.  They  appear  to  be  attracted  by  the 
outpoured  lymph  or  its  products  ;  the  power  of  attraction  thus  exhibited 
is  known  as  "  chemiotaxis." 

Thus  in  a  short  time  the  spaces  between  and  around  the  wounded 


HEALING 


21 


surfaces  contain,  in  addition  to  lymph  and  cells  derived  from  the 
blood,  other  cells  derived  from  the  connective  tissue,  which  possess  the 
power  of  again  forming  fibrous  tissue,  to  which  they  owe  the  name  of 
"fibroblasts." 

In  addition  to  these,  other  cells  of  uncertain  origin,  known  as  "phago- 
cytes/' are  found  able  to  destroy  debris  and  foreign  bodies. 

Further  changes  take  place  in  the  walls  of  the  vessels,  more  particularly 
of  the  capillaries.  Close  to  the  part  where  they  have  been  divided  and 
sealed  off  by  clot  there  appear  buds  of  cells  derived  from  the  endothelial 
lining,  which  grow  out,  becoming  later  hollow  tubes  or  branches  of  the 
capillaries  already  present.  These  buds  approach  and  join  the  buds  or 
branches  from  neigh- 
bouring vessels,  on 
the  other  side  of  the 
wound,  growing 
across  the  mass  of 
plastic  lymph.  In 
this  way  the  circula- 
tion is  restored 
across  the  gap.  This 
mixture  of  growing 
capillaries  and  fibro- 
blastic cells  is  known 
as  ••granulation  tis- 
sue "  and  is  present 
to  some  degree  with- 
in about  twenty-four 
hours  of  the  initial 
lesion.  While  this  is 
going  on,  the  cells  in 
the     exuded    lymph 

multiply  and  remove  the  lymph  and  blood  cells  by  devouring  them. 
Some  of  these  cells  migrate  into  the  blood-vessels  again,  while  others 
surround  themselves  with  fine  strands  of  fibrous  tissue  and  gradually 
assume  the  appearance  of  ordinary  connective-tissue  cells  from  which 
they  originate.  Others  again  grow  large,  become  multinucleate  (called 
giant  cells),  and  have  the  special  power  of  eroding  and  removing 
foreign  bodies,  whether  sutures,  fragments  of  necrotic  tissue,  dead  leuco- 
cytes, &c.  (in  bone  the  large  myeloplaxes  are  of  this  type).  The  final 
result  is  the  transformation  of  the  wound  into  a  mass  of  fibrous  tissue 
traversed  by  new  capillaries  and  firmly  continuous  with  the  surrounding 
tissues.  Such  a  mass  of  connective  tissue  is  described  as  a  scar  or  "cicatrix," 
and  the  process  is  known  as  healing  by  "cicatrization."  Such  a  cicatrix  takes 
from  one  to  three  weeks  to  form,  depending  on  the  vitality  of  the  tissues. 
The  scar  is  at  first  red,  bulky,  and  soft  from  the  hypersemia  and  exudation, 
but  as  the  by-products  of  repair  are  removed  and  the  newly  formed  fibrous 


Fig.  3.     Granulation  tissue  (magnified).     Showing  round  cells, 
spindle  cells  and  formation  of  new  capillaries. 


22 


A  TEXTBOOK  OF  Sl'RGERY 


tissue  contracts, the  scar  becomes  pale,  shrunken,  and  very  linn  and  tough, 
the  surface  being  retracted  below  the  level  of  surrounding  tissues. 

Finally,  in  the  example  taken  the  cells  on  the  surface  of  the  scar  assume 
the  character  of  those  lining  the  peritoneum  generally. 

When  repair  follows  inflammatory  reaction  on  the  above  lines,  healing 
1  to  occur  by  "  primary  union,"  "  per  primam,"  or  "  first  intention." 

The  process  takes  place  in 
the  same  way  on  the  surface 
of  the  body  under  similar 
conditions,  viz.  good  apposi- 
tion of  the  edges  of  the 
wound  and  asepsis,  the  only 
addition  being  that  there  is 
some  multiplication  of  the 
surface  epithelium  to  restore 
the  breach  in  its  continuity. 
Detached  parts,  if  small,  may 
unite  in  this  manner,  e.g.  the 
tip  of  the  nose  or  of  a  finger, 
and  grafts  of  skin  are  often 
made  use  of  in  practice.  The 
process  of  repair  will  be  modi- 
fied in  detail  if  the  edges  of 
the  wound  are  not  in  apposi- 
tion, either  because  tissue  has 
been  removed  so  that  appo- 
sition is  not  possible,  or  from 
neglect  of  suturing,  or  inter- 
vention of  blood  clot  or 
foreign  body,  or  on  account 
of  infection  of  the  wound. 
In  the  healing  of  an  open 
wound  or  raw  surface  the  un- 
derlying changes  are  similar 
to  those  already  described. 
There  is  an  exudation  of  lymph  on  the  raw  surface  containing  migrating 
blood  and  connective-tissue  cells  ;  capillary  buds  form  into  loops,  and  the 
raw  surface  becomes  covered  with  fine,  velvety  projections  (capillary  loops), 
discharging  thin,  serous  material.  These  capillary  loops,  covered  with 
fibroblasts  in  various  stages  and  other  cells,  are  called  "  granulations."  If 
the  surface  be  kept  aseptic  the  reaction,  i.e.  hyperemia  and  exudation,  will 
be  slight  ;  usually  infection,  to  some  degree,  is  unavoidable,  and  there  will 
be  redness,  swelling,  and  pain,  more  noticeable  than  where  primary  union 
is  taking  place. 

Healing  in  such  a  wound  takes  place  from  the  edges   by  ingrowth  of 
epithelium,  which  proliferates  and  grows  in  over  the  granulations,  and 


FlG.  4.  Healing  of  an  incised  wound  of  the  skin. 
Net,,  the  effusion  of  lymph  into  the  gap;  the  round 
cells  of  various  types;  the  spindle  cells  (fibroblasts) ; 
the  formation  of  new  capillaries  across  the  gap;  the 
proliferation  of  the  epithelium  on  the  surface. 


HEALING  23 

these  when  covered  become  converted  into  firm  fibrous  tissue.  Such  a 
method  of  healing  is  called  healing  by  "  granulation  "  or  by  "  second  inten- 
tion." Tf  the  surface  of  such  a  wound  or  granulating  surface  be  folded 
by  suturing  or  otherwise,  so  that  the  granulations  of  one  part  come  in  contact 
with  those  of  another,  union  will  take  place  between  the  granulating  surfaces, 
and  the  condition  becomes  practically  one  of  healing  by  first  intention. 
This  is  a  useful  method  where  infection  of  a  wound  has  prevented  healing 
by  primary  union  and  suppuration  has  taken  place  but  has  subsided. 

In  small  wounds  of  this  nature  the  exudation  of  lymph  dries  on  the 
surface  to  form  a  scab,  and  the  process  of  granulation  and  epithelization 
goes  on  under  this  protective  crust.  This  manner  of  healing  is  called 
"  healing  under  a  scab,"  but  is  simply  a  variety  of  healing  by  granulation. 
If  infection  takes  place  the  scab  will  retain  the  products,  such  as  pus,  and 
healing  be  prevented.  Another  condition  is  where  there  is  considerable 
effusion  of  blood  between  the  edges  of  the  wound.  If  asepsis  is  maintained 
the  capillary  loops  or  granulations  grow  into  this  mass  and  convert  it  into 
fibrous  tissue.  This  is  called  "  healing  in  blood  clo"t,"  and  only  differs 
from  ordinary  primary  union  in  the  amount  of  exudate  present  in  the  hollow 
of  the  wound.  The  disadvantage  of  this  manner  of  healing  is  that  blood 
clot  forms  a  suitable  place  for  infective  bacteria  to  grow,  and  such  wounds 
filled  with  clot  are  very  liable  to  break  down  and  suppurate.  They  are 
therefore  best  avoided  where  possible. 

HEALING   OF  VARIOUS  TISSUES 

It  will  be  noted  that  so  far  healing  has  been  described  as  essentially  a 
function  of,  and  taking  place  in,  simple  connective-tissue,  blood-  and  lymph- 
vessels,  to  a  less  extent  in  epithelium  ;  this  is  very  largely  true,  for  the  more 
complex  and  highly  developed  tissues  have  little  or  no  power  of  regeneration 
and  healing  of  themselves,  hence  any  breach  in  their  substance  is  replaced 
with  few  exceptions  by  a  fibrous  cicatrix,  containing  newly  formed  vessels. 
Connective  tissue,  being  present  in  all  tissues  as  a  scaffolding  material,  is 
also  ready  to  hand  for  the  process  of  repair. 

Repair  of  Bone.  This  is  described  in  detail  in  a  later  section.  The 
process  is  similar  to  ordinary  cicatrization,  but  in  this  case  the  connective- 
tissue  cells  have  the  property  of  reverting  to  bone  cells,  from  which  they 
originated,  and  of  laying  down  bone,  instead  of  simple  fibrous  tissue  ; 
moreover,  cartilage  may  be  formed  in  the  process. 

Cartilage  is  a  singularly  inert  tissue  and  heals  slowly  and  poorly  by 
formation  of  a  fibrous  scar.  Tendons  are  repaired  by  fibrous  cicatrices 
which  tend  to  assume  the  structure  of  tendon.  Muscles,  gland  cells,  and 
those  of  the  central  nervous  system  have  no  power  of  regeneration  ;  damage 
in  these  structures  is  made  good  by  fibrous  cicatrices,  with  corresponding 
loss  of  function. 

Peripheral  nerves  have  the  power  of  regeneration  if  their  continuity  with 
the  central  nervous  system  is  restored  ;  the  nerve  fibres  are,  however, 
simply  cell-processes,  and  in  such  lesions  as  division  of  peripheral  nerves 


24  A  TKXI  BOOK  OF  SURGERY 

the  cells  are  doI  deal  royed  :  should  destruction  of  nerve  cells  occur  they  are 

Bimply  replaced  by  ordinary  scar  tissue,  and  the  nerve  fibres  never  regenerate. 

Tin    Skin.     In   this   instance  only  the  simpler  elements  are  replaced, 

viz.  the  epithelium  and  white  fibrous  tissue  ;  the  more  elaborated  structures, 

as  clastic  tissue,  hair  follicles,  sweat  and  sebaceous  glands,  are  not  regenerated 
unless  some  of  their  structure  remains.  Hence  the  smooth,  thin,  inelastic, 
hairless  nature  of  scars  of  the  integument  in  cases  where  the  whole  thickness 
of  skin  has  been  destroyed. 

VARIATIONS,  COMPLICATIONS,   AND   SEQUELS  OF   INFLAMMATION 

In  the  type  of  inflammation  described  above  the  conditions  postulated 
in  the  definition  of  this  process  were  fairly  strictly  observed,  i.e.  the  damage 
to  the  tissues  was  not  of  such  severity  as  to  prevent  the  protective  response, 
or,  in  other  words,  there  was  not  complete  destruction  of  tissue.  It  often 
happens,  however,  that  there  is  sufficient  damage  at  the  time  of  injury,  e.g. 
in  case  of  burns  and  crushes,  or  the  lesion  is  progressive,  as  in  case  of  infective 
conditions,  so  that  more  or  less  of  the  tissue  is  rendered  incapable  of  reacting, 
and  tissue  degenerations  and  necroses  take  place,  which  complicate  the 
picture  of  inflammation  and  lead  it  to  assume  a  more  severe  and,  clinically, 
a  more  obvious  type.  Taking,  for  example,  an  infective  inflammation, 
such  as  a  boil,  pneumonia,  appendicitis,  or  conjunctivitis,  the  reaction 
of  the  vascular  and  other  tissues  is  similar  to  that  already  described,  but 
more  marked. 

(1)  The  vaso-dilatation  and  hypersemia  are  more  widely  spread,  and 
where  superficial  more  conspicuous  to  sight  and  touch,  as  heat,  redness,  and 
swelling.  Further  alterations  take  place  in  the  walls  of  the  blood-vessels 
in  the  vicinity,  whereby  the  blood  flow  becomes  slowred  and  finally  may 
cease  (stasis),  and  clotting  of  the  stagnant  blood  (thrombosis)  may  occur. 

(2)  The  exudation  from  the  vessels  is  greater,  so  that  the  surrounding 
tissues  are  filled  with  fluid  and  migrated  cells,  causing  the  skin  over  the 
lesion  to  appear  puffy  and  even  waxy  and  shiny,  from  the  great  stretching 
it  undergoes.  The  puffy  skin  will  be  indented,  or  is  said  to  "  pit,"  on  the 
pressure  of  an  examining  finger,  leaving  a  depression  which  takes  some  time 
to  become  obliterated.  This  infiltrated  condition  is  known  as  oedema,  or 
excess  of  fluid  in  the  tissues.  If  the  reaction  is  very  acute,  i.e.  the  injury 
great,  ha)morrhage  from  degeneration  and  giving  wray  of  the  blood-vessels 
may  take  place,  causing  hemorrhagic  exudate  to  appear  into  the  substance 
of  the  inflamed  tissues  or  on  their  surface. 

(3)  The  cells  which  have  migrated  into  the  inflamed  area  may  not  be 
able  to  overcome  the  adverse  influences  of  the  infection,  and  various  degenera- 
tions will  take  place.  These,  although  occurring  during  inflammation. 
must  be  regarded  as  instances  of  failure  of  the  inflammatory  reaction  to  get 
the  better  of  the  damaging  influence  rather  than  as  part  of  inflammation 
proper.     Amongst  such  degenerative  changes  are: 

(a)  Cloudy  swelling  ;  the  cells  swell  up,  becoming  granular  and  losing 
the  staining  reactions  of  body  and  nucleus.     Recovery  from  this  condition 


COURSE  OF  INFLAMMATION  25 

is  possible  up  to  a  point,  after  which  the  cell  definitely  dies  and  (b)  is  said 
to  be  "  necrosing,"  the  protoplasm  disintegrates,  and  the  structure  as  seen 
with  the  microscope  still  more  obscured.  Such  degenerative  changes  affect 
not  only  the  cells  of  the  exudate  but  also  those  of  the  tissue  or  organ  affected, 
being  more  obvious  in  richly  cellular  organs  such  as  the  liver  or  kidney. 
Besides  this  degeneration  of  the  cells  in  the  exudate  there  may  be  other 
evidence  that  the  struggle  is  not  altogether  in  favour  of  the  tissues.  Where 
the  result  is  in  favour  of  the  tissue  the  round-celled  infiltration  will  become 
absorbed  for  the  most  part,  the  remainder  becoming  fibrous  tissue  to  supply 
any  defect  which  may  have  resulted.  Where  there  is  difficulty  in  achieving 
this  healing,  from  adverse  influences,  e.g.  toxins,  there  is  a  tendency  for 
fibroblasts  or  other  cells  of  the  exudate  to  become  large  and  multinucleate. 
Such  giant  cells  are  very  characteristic  of  tuberculous  infections  and  other 
chronic  inflammations. 

The  formation  of  giant  cells  may  fairly  be  regarded  as  one  step  removed 
from  cell  degeneration,  as  the  latter  often  occurs  close  to  giant-cell  forma- 
tions ;  indeed,  parts  of  giant  cells  are  not  infrequently  degenerated  in  a 
granular  manner,  losing  their  staining  reactions,  as  is  well  seen  in  the 
caseation  of  tuberculous  foci. 

COURSE  AND  TERMINATIONS  OF   INFLAMMATION 

The  process  of  inflammation  may  terminate  in  three  main  ways  : 
(1)  Resolution;  (2)  Cicatrization;  (3)  Necrosis  and  Degenerations  of 
various  sorts. 

(1)  In  Resolution  the  hypersemia  passes  off,  the  exudation  is  re-absorbed, 
and  the  part  returns  to  the  normal  state,  without  any  formation  of  fibrous 
or  scar  tissue.  This  termination  is  usually  found  in  mild  forms  of  inflamma- 
tion due  to  trauma,  such  as  that  caused  by  lodgment  of  a  foreign  body  in 
the  conjunctiva,  or  sprains  of  joints,  seldom  where  due  to  infections  except 
when  very  mild,  as  coryza  ;  yet  in  some  instances  even  severe  infections, 
such  as  lobar  pneumonia,  to  a  very  large  extent  clear  up  in  this  manner. 

(2)  Cicatrization  is  the  common  manner  of  termination  of  inflammatory 
processes,  as  instanced  already  in  the  healing  of  an  aseptic  wound,  in  which 
it  occurs  directly;  after  infections,  healing  may  take  place  in  a  similar 
manner,  but  very  frequently  an  intermediate  stage  of  necrosis  of  tissue, 
such  as  suppuration,  ulceration,  gangrene,  &c,  has  to  be  passed  through 
before  the  healing  fibrosis  takes  place. 

(3)  Sometimes  the  adverse  agent  (usually  an  infective  organism  or  severe 
injury,  such  as  a  burn)  is  too  powerful  for  the  reaction  of  the  tissues, 
and  then  destruction  of  the  inflamed  tissues  takes  place  by  various  processes 
described  later  (suppuration,  gangrene.  &c).  Such  adverse  circumstances 
may  cause  such  a  spread  of  inflammation  that  life  may  be  destroyed  by  the 
absorption  of  poisons  from  the  inflamed  focus  (toxsemia),  or  by  general 
spread  of  the  infection  throughout  the  body  (septicaemia),  or  after  a  while 
the  tissues  may  again  get  the  upper  hand  and  healing  by  cicatrization  take 
place. 


26  A  TEXTBOOK  OF  SURGERY 

VARIETIES  OF   INFLAMMATION 

Although  the  underlying  phenomena  of  inflammation  are  always  the 
same,  viz.  certain  changes  in  the  vascular  structures  and  other  tissues,  yet 
considerable  differences  are  noted  clinically  and  are  useful  for  descriptive 
purposes.  These  differences  depend  on  the  severity  of  the  stimulus  and 
corresponding  reaction,  the  part  of  the  tissue  or  organ  affected,  the  position 
of  the  affection,  the  part  played  by  the  different  factors  in  the  tissue  react  ion, 
and.  finally,  the  underlying  cause. 

Thus,  (a)  with  regard  to  severity,  the  terms  fulminating,  acute,  subacute, 
chronic,  are  applied.  Gangrenous,  phagedenic,  also  bear  testimony  to  the 
severity. 

(b)  With  regard  to  situation,  the  terms  parenchymatous,  interstitial, 
catarrhal,  croupous,  are  employed. 

(c)  Owing  to  the  different  parts  played  by  the  various  factors  in  the 
reaction  we  find  the  terms  phlegmonous,  serous,  hemorrhagic,  fibrosing. 

(d)  With  regard  to  the  underlying  cause  the  most  important  distinction 
is  between  causes  -which  have  ceased  to  act,  as  crushes,  burns,  &c,  and 
those  which  are  acting  constantly,  as  infections,  foreign  bodies. 

(a)  Acute  Inflammations.  The  phenomena  have  been  described 
already  in  the  general  account  of  inflammation,  and  the  signs  are  obvious 
in  a  few  hours  or  days  according  to  the  situation.  When  there  is  a  very 
sharp  response  the  condition  is  sometimes  described  as  "  fulminating."  In 
such  cases  the  reaction  is  very  marked  and  appears  rapidly  ;  there  is  great 
hyperemia,  exudation,  and  oedema,  often  going  on  to  massive  destruction 
of  tissues,  such  as  rapid  suppuration  or  even  gangrene.  In  such  conditions 
the  exudation  is  fairly  often  hsemorrhagic,  owing  to  bursting  of  the  hyperaemic 
vessels  from  toxic  degeneration.  As  instances  of  such  inflammations  we  may 
point  out  fulminating  appendicitis,  gangrenous  cellulitis,  acute  pancreatitis,  &c. 

In  subacute  inflammations  the  condition  develops  more  slowly  ;  the  local 
signs  are  of  more  moderate  nature  as  regards  heat,  redness,  swelling,  pain, 
and  destructive  sequelae  are  less  usual,  though  inflammation  from  infection 
may  commence  quietly  and  pass  into  an  ultra-acute  stage  as  the  infection 
spreads.  Inflammation  due  to  mechanical  violence  is  often  of  this  nature, 
e.g.  sprains,  healing  of  aseptic  wounds.  In  such  cases  the  reaction  ends 
in  resolution  or  slight  cicatrization. 

Chronic  inflammations  are  characterized  by  slow  advance  of  the  process, 
formation  of  granulation  and  fibrous  tissue  being  much  in  evidence.  Exuda- 
tion is  often  more  fluid  ;  degenerative  sequelae  are  fairly  common,  but  take 
place  slowly,  destruction  of  tissue  by  suppuration  and  ulceration  being 
common,  while  rapidly  spreading  necrosis  or  gangrene  is  practically  unknown. 
The  common  causes  of  chronic  inflammation  are  infection  with  tubercle 
and  syphilis,  but  repeated  small  injuries  account  for  many  cases.  Moreover, 
acute  infections,  inflammations,  often  become  chronic  where  the  reaction 
between  the  tissues  and  the  cause  of  inflammation  remains  undecided  for 
a  considerable  time. 


VARIETIES  OF  INFLAMMATION  27 

(b)  "With  regard  to  the  tissue  affected. 

The  term  'parenchymatous  is  applied  to  inflammations  affecting  principally 
the  main  tissue  of  an  organ,  e.g.  the  secreting  cells  of  the  kidney ;  while, 
if  the  reaction  is  chiefly  in  the  supporting  connective  structures,  interstitial 
inflammation  is  said  to  be  present. 

A  catarrhal  inflammation  is  one  affecting  an  epithelial  covered  surface, 
usually  a  mucous  membrane,  less  often  the  skin.  Since  there  is  a  free 
surface  bounding  the  area  of  inflammation  on  one  side,  there  will  be  exuda- 
tion from  this  surface,  which  will  contain  desquamated  epithelial  cells  in 
addition  to  the  leucocytes  usually  present  in  such  exudates,  and  the 
whole  form  a  viscid,  turbid  liquid  known  as  muco-pus.  Coryza,  or 
cold  in  the  head,  and  gonorrhoea  are  common  examples  of  catarrhal 
inflammations. 

When  the  exudation  is  fibrinous  and  coagulates  on  the  surface  of  an 
inflamed  part,  the  inflammatory  process  is  described  as  croupous.  A 
croupous  exudate  may  be  found  on  mucous  membranes,  but  more  usually 
on  serous  surfaces,  such  as  the  pleura  or  peritoneum.  Such  a  plastic 
membrane  may  be  dissolved  and  form  pus,  or  become  organized  into  fibrous 
tissue,  forming  "  adhesions  "  binding  together  adjacent  surfaces  of  the 
serous  membrane. 

A  somewhat  similar  condition  occurs  on  mucous  surfaces,  but  in  addition 
to  the  fibrinous  exudation  there  is  necrosis  of  the  superficial  layers  of  the 
mucous  membrane,  which,  infiltrated  and  mixed  with  the  coagulated  exudate, 
forms  a  "  false  membrane."  A  false  membrane  is  fairly  tough  and 
can  be  stripped  off,  leaving  a  raw  bleeding  surface.  Such  an  inflammation 
is  called  diphtheritic,  and  is  a  combination  of  croupous  inflammation  with 
superficial  necrosis. 

Inflammation  resulting  from  infection  with  the  Klebs-Loeffler  bacillus 
of  diphtheria  is  a  well-known  example  of  this  form  of  inflammation. 

(c)  Phlegmonous  inflammation  is  a  term  applied  to  rapidly  spreading 
inflammation,  usually  of  loose  connective-tissue  structures,  as  the  sub- 
cutaneous tissues  and  intermuscular  planes,  with  great  exudation  and 
oedema  and  tendency  to  diffuse  suppuration.  These  inflammations  are 
always  infective  in  origin  and  are  likely  to  assume  even  more  severe  forms, 
such  as  phagedena  or  gangrene,  which  are  apt  to  follow  swiftly  in  the 
train  of  phlegmonous  inflammation  or,  as  it  is  often  called,  cellulitis.  The 
terms  suppurative,  localized,  diffuse,  &c,  need  no  further  explanation. 

(d)  As  has  been  pointed  out,  the  causal  factor  in  inflammation  is  most 
essential  to  determine,  whether  the  cause  has  ceased  to  act,  as  in  sprains, 
burns,  &c,  or  whether  there  is  a  persistent  cause  of  such  a  simple  nature 
as  a  piece  of  grit  in  the  cornea,  or  a  fish  bone  in  the  larynx,  or  some  infective 
organism  ;  for  if  the  cause  has  ceased  to  act  inflammation  is  purely  repara- 
tive, but  if  still  present  it  will  need  removal  if  possible.  Thus  it  is  little 
use  treating  an  inflamed  eye  with  soothing  lotions  if  a  piece  of  steel  is 
embedded  in  the  cornea. 

In  addition  to  the  primary  or  exciting  causes,  it  should  be  recognized 


28  A  TEXTBOOK  OF  SURGERY 

that  certain  conditions  of  the  tissues  predispose  to,  or  render  inflamma- 
tion likely  to  arise  and  severe  sequels  more  prone  to  ensue  than  they  are 
in  normal  tissues.     Such  predisposing  causes  are  local  and  general. 

Local  predisposing  causes  are  disturbances  of  the  local  blood-  and  nerve- 
supply,  e.g.  varicose  veins,  spinal  cord  and  nerve  injuries,  &c. 

i  reneral  predisposing  causes  are  malnutrition,  as  from  old  age,  or  general 
diseases,  such  as  diabetes,  chronic  nephritis,  alcoholism,  syphilis,  scurvy, 
prolonged  fevers  and  their  depressing  results,  e.g.  enteric. 

CLINICAL  APPEARANCES   IN   INFLAMMATION 

These  may  be  divided  into  local  and  general. 

Mention  has  already  been  made  of  the  classic  signs  of  inflammation, 
heat,  redness,  swelling,  pain,  and  disordered  function.  The  meaning  of 
these  signs  has  to  be  explained,  and  it  will  be  well  to  consider  them  in  detail 
and  point  out  possible  sources  of  error. 

In  the  first  place  it  is  as  well  to  note  that  the  diagnosis  of  inflammation 
must  often  be  made  in  the  absence  of  most  of  these  signs.  For  example, 
if  the  surgeon  attending  a  possible  case  of  appendicitis  were  in  the  habit 
of  waiting  till  the  above  signs  were  present  he  would  certainly  lose  a  large 
number  of  patients. 

(1)  Heat  and  redness,  i.e.  hypersemia,  are  only  found  when  the  inflamma- 
tion is  tolerably  near  the  surface.  Thus  one  or  both  of  these  signs  may 
be  noted  in  inflammations  or  abscesses  of  subcutaneous  tissues  or  superficial 
joints  and  bones,  as  the  knee,  wrist,  ankle,  tibia,  &c.  In  deep  structures, 
e.g.  hip  joint,  appendix,  these  signs  will  not  be  found  till  very  late,  if  at  all. 

Redness  is,  of  course,  absent  in  avascular  structures,  such  as  the  cornea 
and  cartilage,  but  in  such  cases  the  surrounding  tissues,  e.g.  the  conjunctiva, 
will  show  hyperemia.  Where  the  redness  passes  into  purple,  and  the  skin 
appears  waxy  and  shiny,  the  probability  is  that  the  limits  of  simple  inflamma- 
tion are  passed  and  suppuration  is  taking  place. 

(2)  Swelling  will,  as  a  rule,  be  found  early,  except  in  deep-seated  struc- 
tures and  is  due  to  hyperemia  and  exudation.  When  such  swelling  is 
cedematous  or  "  pitting  "  on  pressure  the  inflammation  is  generally  severe 
and  often  suppurative  in  nature.  The  swelling  may  map  out  in  its  distribu- 
tion some  natural  cavity  or  organ,  such  as  the  synovial  membrane  of  a  joint, 
a  bursa,  the  epididymis,  and  be  helpful  in  definitely  locating  the  trouble  to 
some  special  part. 

(.3)  Pain  is  perhaps  the  most  important  early  symptom,  especially  if 
combined  with  the  sign  tenderness  or  pain  caused  by  deep  pressure.  In 
fact,  our  diagnosis  of  an  acute  inflammation  often  rests  on  the  presence  of 
pain,  deep  tenderness,  and  some  evidence  of  disordered  function.  The 
cause  of  pain  in  inflammation  is  mostly  due  to  pressure  on  the  nerve  fila- 
ments, by  the  hyperemia  and  exudation  into  the  tissues,  in  other  cases  by 
actual  irritation  of  nerves  by  the  toxins  secreted  by  the  causal  agent,  or 
by  the  latter  itself,  as  in  the  case  of  foreign  bodies  and  calculi. 

The  pain  of  inflammation  varies  in  different  tissues ;  thus  in  epithelial 


SIGNS  OF  INFLAMMATION  29 

structures  it  is  described  as  burning,  scalding,  or  suggesting  the  presence 
of  grit,  e.g.  urethra,  conjunctiva. 

In  serous  membranes  the  pain  is  sharper  and  described  as  stabbing, 
e.g.  in  the  pleura  or  peritoneum,  in  bones  as  boring.  When  pain  is  of  a 
throbbing  nature,  i.e.  with  exacerbations  which  are  synchronous  with  the 
pulse,  the  condition  is  certainly  acute,  and  suppuration  is  likely  to  be  taking 
place. 

The  pain  of  inflammation  may  be  localized  in  the  inflamed  part  or 
referred  to  the  periphery  along  nerves  which  supply  the  periphery  and  the 
inflamed  region  ;  thus  pain  radiating  to  the  testis  is  frequent  in  renal 
affections,  while  in  disease  of  the  hip  joint  pain  is  often  referred  to  the 
knee.  In  spinal  caries  a  common  symptom  is  belly-ache  from  pressure 
on  the  dorsal  nerves  which  are  distributed  to  the  abdomen. 

Pain  due  to  inflammation  varies  much  in  severity  in  different  parts, 
being  especially  severe  in  structures  surrounded  by  dense  coverings  and 
abundantly  supplied  with  nerves.  Thus  a  small  area  of  inflammation  in 
the  nail-pulp,  being  confined  between  the  bone  of  the  phalanx  and  the  nail, 
is  extraordinarily  painful ;  boils  of  the  tough  fibrous  tissue  of  the  nose  and 
external  auditory  meatus,  though  small,  are  most  painful ;  the  testis  when 
inflamed  is  very  tender  owing  to  the  dense  tunica  albuginea  increasing  the 
pressure  of  the  inflammatory  process.  On  the  other  hand,  widespread 
nflammation  in  lax  subcutaneous  tissues  may  cause  very  little  pain ;  an 
inflammation  of  the  back  of  the  hands  is  far  less  painful  than  when  in  front 
under  the  dense  palmar  fascia. 

That  the  pain  of  inflammation  is  due  to  the  pressure  of  the  hyperaemia 
and  exudation  is  borne  out  by  the  fact  that  it  increases  on  pressure  (tender- 
ness) and  also  by  augmenting  the  blood  pressure  in  the  part,  as  by  allowing 
the  part  to  hang  down,  whence  the  value  of  raising  an  inflamed  part  as  a 
palliative  measure. 

(4)  Disordered  function  occurs  partly  owing  to  the  pain  in  the  inflamed 
part,  which  is  aggravated  by  movement  or  other  function ;  partly  by  the 
pressure  of  the  exudation,  causing  impairment  of  the  blood-  and  nerve-supply 
to  the  part  and  consequent  malnutrition  of  the  tissues  involved  ;  partly 
by  poisoning  of  the  cells  by  toxins  if  the  cause  is  infective  ;  partly  by 
mechanical  impediment,  as  in  the  inability  to  bend  fingers  properly  in  case 
of  whitlow,  from  the  effusion  into  the  tendon  sheaths. 

Disordered  function  may  be  in  the  direction  of  (a)  diminished  activity  of 
the  part  affected,  as  in  cases  of  anuria  or  cessation  of  the  kidney  to  secrete 
urine,  from  renal  inflammation  or  nephritis,  of  intestinal  paralysis  in  peri- 
tonitis, or  (b)  increased  activity,  as  in  the  increased  frequency  of  micturition 
noted  in  tuberculosis  of  the  kidney  or  in  cystitis. 

GENERAL   OR   SYSTEMIC   RESULTS  OF   INFLAMMATION 

The  effect  of  inflammation  alone  on  the  general  condition  is  practically 
nothing.  Thus  the  healing  of  an  aseptic  wound  produces  no  general  changes. 
Slight  fever   is  not  infrequently,  however,  associated  with  the  processes 


30  A  TEXTBOOK  OF  SURGERY 

of  repair  in  their  earlier  stages  ;  after  fractures  a  rise  of  temperature 
to  as  much  as  101°  is  common,  as  is  delirium,  though  there  is  no  evidence 
of  infection.  Severe  general  conditions,  such  as  high  fever,  leucocytosis, 
tissue  degenerations,  paralyses,  &c,  associated  with  inflammations,  are 
always  due  to  some  infection  which  causes  the  inflammation  and  also  the 
toxaemia.  Such  general  states  form  no  part  of  inflammation  proper.  Where 
some  very  important  organ,  such  as  heart,  brain,  intestine,  or  kidney,  is 
affected  general  changes  will  result,  but  these  are  primarily  due  to  the 
disordered  function  of  the  organ  affected,  i.e.  of  local  origin,  not  necessarily 
inflammatory. 

DIAGNOSIS  OF  INFLAMMATION 

Since  pure  inflammation  is  essentially  reparative  in  nature  and  is  the 
reply  of  the  tissues  to  most  lesions,  it  follows  that  inflammation  forms  an 
important  part  of  nearly  all  lesions,  whether  traumatic,  infective,  or  due 
to  other  cause,  and  our  aim  is  not  so  much  to  diagnose  inflammation  as  to 
recognize  the  cause  thereof  and  assist  Nature  in  her  conduct  of  the  healing 
process.  Diagnosis  can  only  rationally  be  discussed  under  the  affections 
of  special  tissues  and  organs.  In  other  words,  we  must  form  some  prognosis 
of  the  process  in  any  given  case  and  decide  whether  it  is  advancing  towards 
healing  or  whether  the  causal  agent  is  gaining  the  victory  or  likely  to  do 
so,  rendering  drastic  interference  urgently  needed,  as,  for  instance,  in  acute 
appendicitis,  spreading  cellulitis,  &c. 

TREATMENT  OF   INFLAMMATION 

From  what  has  been  already  stated  it  will  be  clear  that  it  is  not  inflamma- 
tion which  requires  treatment  so  much  as  the  active  cause  of  inflammation  ; 
therefore  the  first  step  is  to  remove  the  cause  if  this  is  possible  and  if  it 
has  not  ceased  to  act,  as  in  case  of  injuries,  e.g.  fractures,  sprains,  burns, 
&c.  Removal  of  the  cause  when  still  present  and  active  is  of  the 
first  importance.  Thus  a  foreign  body  in  the  cornea  or  larynx  demands 
immediate  removal.  Similarly  an  acutely  inflamed  appendix,  though 
usually  secondary  to  and  resulting  from  an  infection,  may  be  regarded  as 
the  prime  cause  of  incipient  peritonitis  and  needs  removal  equally  with 
the  former  bodies.  Drugs  may  be  used  to  remove  the  cause  ;  thus  urate 
of  soda,  in  a  case  of  gout,  is  removed  from  joints  by  colchicum  and  alkalis  ; 
malarial  organisms  are  destroyed  by  quinine,  the  spirochsete  of  Schaudinn 
by  salvarsan,  &c.  Having  removed  the  cause  the  inflamed  part  is  placed 
under  the  best  conditions  to  allow  nature  to  carry  out  the  reparative  inflam- 
mation. In  simple  inflammations,  e.g.  the  healing  of  fractures,  splinting, 
or  other  means  of  restraint,  will  be  suitable  at  first  to  maintain  apposition 
of  parts  and  give  rest,  but  sooner  or  later  an  attempt  must  be  made  to  restore 
function.  This  is  done  by  improving  the  blood-supply  with  massage  and 
use  of  the  part.  Combinations  of  rest  and  exercise  are  the  most  suitable 
methods  of  treating  the  simpler  inflammations. 

Apart  from  the  rest  and,  later,  massage  and  movements,  the  general 


TREATMENT  OF  INFLAMMATION  31 

measures  for  dealing  with  inflammation  are  chiefly  directed  to  controlling 
the  blood-supply  of  the  inflamed  part  by  application  of  heat  or  cold.  It 
may  seem  curious  that  two  opposite  forces,  heat  and  cold,  are  used  to  treat 
this  condition.  The  reasons  are  as  follows  :  cold  applied  to  the  surface 
diminishes  the  blood-supply  by  contracting  the  arterioles  and  relieves  the 
pain  due  to  congestion,  while  also  to  some  degree  diminishing  the  exudation, 
and  so  tends  to  leave  less  lymph,  &c,  to  be  removed  later.  Cold  is  mainly 
useful  in  relieving  pain,  and  to  be  used  in  minor  degrees  of  inflammation 
such  as  are  often  due  to  trauma. 

Heat  in  the  form  of  poultices,  fomentations,  hot  air,  radiant  heat,  &c, 
also  is  very  largely  important  as  an  anodyne  ;  in  addition,  by  causing  an 
increased  flow  of  blood  to  the  part,  if  superficial,  it  brings  into  play  a  greater 
amount  of  anti-bodies  and  helps  in  the  struggle  against  infection  when  the 
latter  is  the  cause  of  inflammation. 

In  addition  to  active  or  arterial  hyperaemia  produced  by  heat,  passive 
hyperemia  or  venous  congestion  may  be  used  for  limbs  (Bier).  A  bandage 
is  placed  on  the  proximal  side  of  the  lesion,  just  tight  enough  to  produce 
venous  stagnation  ;  this  congestion  is  maintained  for  one  or  more  hours. 
This  method  is  inadvisable  in  acute  cases,  since  in  the  absence  of  a  good 
blood  supply  such  conditions,  which  are  usually  infective,  may  progress 
rapidly.  In  certain  chronic  affections,  however,  especially  of  joints,  pain, 
at  any  rate,  is  often  relieved  by  promoting  venous  congestion,  though  whether 
any  good  results  apart  from  this  is  uncertain.  Somewhat  similar  is  the 
plan  of  cupping,  either  with  the  old-fashioned  cups  which  were  placed  on 
the  skin  after  the  air  inside  the  cup  had  been  rarefied  by  heat.  The  skin 
was  sucked  up  into  the  cup  by  condensation  of  the  air  as  it  cooled  (dry 
cupping),  or  if  incisions  had  been  made  into  the  skin,  blood  and  serum 
exuded  (wet  cupping).  The  latter  method  was  practically  a  glorified  leech- 
bite.  A  modern  development  of  this  method  is  by  the  use  of  Klapp's  suction 
bells,  which  are  also  cups,  but  the  air  is  exhausted  by  means  of  a  syringe. 
When  applied  over  the  unbroken  skin,  little  results  except  perhaps  the 
relief  of  pain.  "When,  however,  such  bells  are  applied  over  incisions  or 
sinuses  leading  into  inflamed  tissues  their  suction  promotes  a  flow  of  serum, 
and  the  consequent  washing  through  of  inflamed  tissues  is  likely  to  be 
beneficial.  Such  treatment  is  directed  rather  to  the  infection  than  the 
inflammation,  but,  as  has  been  mentioned,  in  practice  these  conditions  are 
often  synonymous. 

Incisions  into  inflamed  parts  may  act  by  removing  the  cause  or  a  large  part 
of  the  latter,  as  when  an  abscess  is  opened,  also  by  allowing  serum  to  exude, 
a  more  free  flow  of  the  latter  is  allowed,  and  the  anti-bodies  in  the  serum 
bathing  the  inflamed  tissues  assist  in  quelling  infection.  Thus  incisions  are 
rather  directed  to  curing  the  infective  cause  than  the  inflammation  present. 
In  the  same  way  general  treatment  is  directed  to  diminishing  the  virulence 
of  the  infection  whether  by  removing  toxins  by  purgation,  promoting  free 
action  of  the  kidneys,  by  maintaining  strength  with  nourishing  food  and 
stimulant,  or  the  use  of  specific  antitoxins  and  vaccines. 


CHAPTER  IV 

DEGENERATIVE   AND   NECROTIC  SEQUELS   OF   INFLAMMATION 
—SUPPURATION 

Mention  has  already  been  made  of  conditions  following  inflammation  when 
the  reaction  of  the  tissues  is  not  enough  to  cause  immediate  repair,  but 
some  local  destruction  of  tissue  takes  place.  Such  conditions  are  described 
under  the  terms  suppuratu  it.  ulceratu  n.  gangrene.  The  two  last  conditions 
may  occur  quite  apart  from  inflammation,  though  often  as  sequela?  to  the 
latter,  but  suppuration  when  of  infective  origin,  as  is  always  the  case  in 
practice,  invariably  follows  in  the  train  of  inflammation. 

SUPPURATION 

By  this  term  is  meant  destruction  of  the  products  of  inflammation  with 
death  of  the  cellular  elements  and  liquefaction  of  these  and  the  intercellular 
substance.  When  the  tissues  are  destroyed,  but  not  dissolved  and  liquefied, 
the  dead  mass  is  called  a  slough,  and  the  process  described  as  sloughing  or, 
if  extensive,  gangrene.  Suppuration  in  practice  is  always  the  result  of 
infection  with  micro-organisms,  which  are  of  such  virulence  as  to  overcome 
the  tissue  reaction,  destroy  the  exuded  cells  and  surrounding  tissues  so  that 
they  undergo  the  changes  described  as  cloudy  swelling  and  necrosis,  and 
finally  produce  liquefaction  of  the  dead  mass  by  the  action  of  digestive 
ferments.  Experimentally,  suppuration  has  been  produced  in  the  absence 
of  infection  by  injecting  irritating  liquids,  such  as  croton  oil  or  turpentine, 
into  the  tissues,  but  in  everyday  life  suppuration  may  be  regarded  as 
evidence  of  infection,  although  the  contents  of  an  abscess  may  be  sterile 
owing  to  the  infective  organisms  having  died  out. 

A  considerable  number  of  organisms  have  the  power  of  producing 
suppuration,  and  these  are  generally  grouped  together  as  pyogenic  organisms. 
But  scientifically  we  must  regard  each  form  of  disease  produced  by  such 
organisms  as  a  separate  entity,  since  to  obtain  the  best  results  from  treat- 
ment it  is  often  necessary  to  discover  the  infecting  agent. 

ANATOMY.  The  process  of  suppuration  follows  on  the  lines  described 
in  inflammation.  Hyperemia  is  followed  by  exudation  of  fluid  and  cells. 
In  the  area  of  infection  the  cells  instead  of  holding  their  own  are  killed  by 
t<»xins.  and  together  with  the  exuded  lymph  and  the  infiltrated  tissue  are 
dissolved,  forming  a  liquid  .called  "pus."  If  the  pus  is  contained  in  a 
well-marked  cavity,  the  fluid  mass  is  described  as  an  "  abscess." 

Pus  varies  in  appearance  and  constitution  according  to  the  infecting 
agent  and  the  reaction  of  the  tissues.    The  commonest  variety  which  usually 

32 


ABSCESS  33 

follows  infection  with  staphylococcus  aureus,  but  also  pneumococci.  gono- 
cocci,  &c,  is  a  creamy  fluid  of  yellowish  colour,  specific  gravity  1030,  alkaline 
reaction,  and  slightly  mawkish  odour.  Examined  with  the  microscope 
the  turbidity  is  seen  to  be  due  to  the  presence  of  granular  debris,  still  more 
to  the  presence  of  leucocytes,  and  other  cells  in  various  stages  of  cloudy 
swelling  and  necrosis ;  micro-organisms,  living  or  dead,  are  also  found  if 
careful  enough  examination  be  made.  Such  pus  was  formerly  described 
as  ■•  laudable,"  being  the  usual  concomitant  of  operations  conducted  without 
aseptic  technique,  which  were  sufficiently  fortunate  not  to  undergo  phagedenic 
ulceration  or  gangrenous  changes. 

Other  varieties  of  pus  are  :  sanious,  where  there  is  blood  mixed  with  the 
pus.  suggesting  severe  inflammation  and  rupture  of  the  capillaries  in  the 
abscess  wall ;  ichorous,  where  the  pus  is  thin,  there  being  much  fluid  in 
the  exudate  and  but  few  cells — often  found  in  streptococcal  infections  ; 
curdy,  where  there  are  masses  of  undissolved  fibrin  or  lymph  in  the 
fluid  ;  this  is  often  found  in  pneumococcal  infections,  e.g.  empyema  of  the 
pleura,  pneumococcal  peritonitis,  and  in  some  tuberculous  suppurations ; 
muco-pus,  where  there  is  suppuration  on  a  mucous  surface,  and  the 
pus  formed  is  mixed  with  the  increased  secretion  of  the  mucous  surface, 
as  in  gonorrhoea,  coryza,  &c. ;  stinking  pus  is  found  where  putrefactive 
organisms,  usually  of  the  proteus  type,  are  present,  in  addition  to  the  patho- 
genic organisms  causing  the  suppurative,  as  in  suppuration  connected  with 
bowel  infection,  e.g.  appendicitis,  gangrene  of  the  intestine,  or  intracranial 
suppuration  originating  in  old-standing  middle  ear  disease. 

Suppuration  may  occur  (a)  In  the  interior  of  tissues  or  organs,  when  it 
may  be  (1)  Circumscribed  as  in  abscess  formation,  or  (2)  Diffuse,  as  in  cellulitis 
or  phlegmonous  inflammation  ;  in  which  case  it  is  often  of  streptococcal 
origin. 

(6)  On  a  free  mucous  surface,  the  condition  being  closely  allied  to 
catarrhal  inflammation,  but  the  hypersemia  and  swelling  are  more  severe. 
and  the  exudation  consists  of  pus  mixed  with  mucous  secretion,  i.e.  muco- 
pus. 

(c)  In  a  cavity  which  may  be  lined  with  mucous  membrane  or  endo- 
thelium, such  a  collection  of  pus  inside  a  natural  cavity  is  often  known 
as  an  empyema,  the  term  being  especially  applied  to  such  a  collection  in 
the  pleural  cavity,  but  we  also  have  empyemas  of  the  antrum  of  Highmore, 
of  the  mastoid  antrum,  of  the  frontal  sinus,  of  the  gall-bladder,  &c. 

ANATOMY  OF  AN  ABSCESS 

Where  the  process  of  suppuration  is  circumscribed,  as  in  abscess  forma- 
tion, there  will  be  found  on  section  through  the  mass  passing  from  without 
inwards  : 

(1)  A  zone  of  hypersemia  and  increased  blood  flow,  inside  which  is, 

(2)  A  zone  of  hyperaemia  or  vaso-dilatation,  with  diminished  blood  flow 
and  possibly  stasis  and  even  thrombosis.  In  this  zone  will  also  be  noted 
exudation  of  fluid  and  cells,  both  leucocytes  and  migrating  connective-tissue 


34 


A  TEXTBOOK  <>K  SURGERY 


cells.     In  very  acute  cases  there  will  be  also  rupture  of  small  blood-vessels 
with  extravasation  of  blood. 

(.'>)  Within  this  again  is  a  /.one  of  tissues  and  migrated  cells,  both  in  a 
state  of  cloudy  swelling  and  necrosis  ;    these  vessels  are  completely  throm- 
bosed and  their  contents  under- 
going  degeneration    from   the 
action  of  bacterial  toxins. 

(■1)  Finally,  in  the  centre 
of  all  is  the  collection  of  pus, 
containing  organisms,  living 
and  dead,  together  with  semi- 
digested  cells  ami  fragments  of 
cells  and  tissues. 

As  the  abscess  spreads,  the 
inner  zones  increase  in  size  at 
the  expense  of  their  outer 
neighbours,  till  finally  the 
skin  or  some  hollow  viscus  is 
reached,  the  abscess  bursts  on 
the  surface  of  this  and  the  pus 
is  discharged,  leading  to  forma- 
tion of  a  sinus,  after  which 
healing  may  take  place.  In 
other  cases  the  tissue  reaction 
controls  the  spread  of  infection 
and  capillary  loops  form  in  the 
second  and  third  zones  de- 
scribed, the  exuded  cells  as- 
sume the  role  of  fibroblasts, 
and  thus  a  wall  of  granulation 
tissue  is  formed  round  the  abscess,  which  becomes  fibrous  on  its  outer  limit. 
Such  an  abscess  consists  of  a  quantity  of  pus  surrounded  by  a  zone  of  granu- 
lation and  fibrous  tissue ;  this  may  slowly  increase  in  size,  or  under  favourable 
conditions  the  pus  may  become  absorbed  and  the  granulation  tissue  become 
entirely  converted  into  fibrous  tissue,  often  containing  areas  of  calcification. 
Such  a  termination  is  unlikely  where  the  infection  is  acute,  but  in  slowly 
acting  infections,  e.g.  the  tubercle  bacillus,  such  an  end  is  not  uncommon. 
The  more  slowly  spreading  abscesses  with  well-marked  fibrous  wall  are  often 
known  as  cold  abscesses.  Under  less  favourable  conditions,  arising  from 
severe  infections,  the  process  of  destruction  is  rapid,  the  necrosis  spreads 
swiftly,  large  masses  of  the  tissues  sloughing  round  the  area  of  inflammation 
and  spread  of  organisms  by  blood  and  lymphatics  may  lead  to  general  infec- 
tion and  death. 

Diffuse  suppuration  is  akin  to  the  latter  type  ;  the  defence  of  the  tissues 
is  poor,  and  infective  inflammation,  ending  in  suppuration,  spreads  along  the 
tissue  planes,  as  described  later  under  Cellulitis. 


Fig.  .-,.     Large  (<'1<1  abscess  of  back  secondary  to 

caries  of  the  rilis. 


SIGNS  OF  SUPPURATION 

In  a  general  way  we  may  divide  abscesses  into  acute  and  chronic,  the 
latter  being  known  as  cold  abscesses, since  owing  to  the  v  sry  slight  hyperemia 
in  their  periphery,  they  do  not  feel  hot.  All  grades  of  abscess  are  found 
in  practice,  from  rapidly  advancing  gangrenous  forms  of  suppuration  to 
chronic  fibrosing  conditions  which  take  months  to  become  noticed.  In  the 
more  acute  abscesses  there  is  little  formation  of  granulation  tissue  but  great 
destruction  of  tissues,  while  in  cold  abscess  there  is  always  a  well-formed 
covering  of  granulation  and  fibrous  tissue  surrounding  the  pus. 

GENERAL  EFFECTS  OF  SUPPURATION 

The  general  effects  of  suppuration  are  due  to  the  toxins  of  the  infective 
cause  (bacteria),  and  vary  in  degree,  being  scarcely  noticeable  in  cold 
abscesses,  while  in  an  acute  abscess  all  the  signs  of  profound  toxaemia  may 
be  present,  such  as  fever,  rigors,  sweats,  delirium,  constipation,  leucocytosis  : 
and  later,  degenerations  such  as  simple  wasting,  amyloid  disease,  &c, 
which  will  be  further  discussed  under  Septicaemia. 

SIGNS  OF   SUPPURATION 

Where  an  abscess  is  superficial  the  signs  are  those  of  inflammation, 
more  or  less  well  defined,  viz.  heat,  redness,  swelling,  pain,  and  disordered 
function,  to  which  are  added  (a)  the  feeling  of  fluctuation  in  the  swollen 
mass,  and  (b)  as  the  abscess  approaches  the  surface,  the  skin  becomes  shiny 
and  waxy  in  appearance,  and  if  indented  with  the  finger  there  remains  a 
pit  (pitting  on  pressure).  By  fluctuation  is  meant  an  example  of  the  well- 
known  hydrostatic  law  that  fluids  transmit  pressure  equally  in  all  directions  ; 
if  one  portion  of  the  swelling  (abscess)  be  compressed  with  a  finger  and 
thumb  of  one  hand,  a  finger  of  the  other  hand,  applied  to  a  different  portion 
of  the  swelling,  will  experience  a  sensation  that  the  swelling  there  is  expand- 
ing. Where  suppuration  is  diffuse,  as  in  cellulitis,  fluctuation  will  be  absent, 
but  the  skin  will  feel  boggy  and  the  colour  will  change  from  red  to  various 
shades  of  red-purple,  purple,  or  even  black  if  gangrene  is  commencing. 
When  the  abscess  is  deep-seated,  fluctuation  may  not  be  ascertainable  and 
we  have  to  rely  more  on  the  general  signs,  such  as  initial  rigors,  high  fever, 
polymorpho-nuclear  leucocytosis,  and  a  general  knowledge  of  the  likely 
course  of  the  affection  in  the  part  of  the  body  infected.  Thus  in  the  case 
of  an  appendix  abscess,  there  will  be  usually  a  tender  swelling  palpable  in 
the  lower  abdomen  or  per  rectum,  or  both  ;  fluctuation  will  only  be  noted 
where  the  abscess  is  very  large  and  has  been  left  overlong.  Still  later 
local  heat  and  redness  may  be  found,  but  in  these  days  of  surgical  advance 
very  few  cases  are  left  untreated  till  this  unfortunate  condition  results. 
We  know  from  experience  that  an  inflammatory  swelling  in  this  situation 
never  assumes  any  considerable  size,  especially  if  associated  with  general 
signs,  such  as  rigors,  fever,  constipation,  vomiting,  &c,  without  suppuration 
having  occurred,  and  may  confidently  diagnose  an  appendix  abscess  although 
fluctuation,  as  well  as  some  of  the  signs  of  inflammation,  as  heat  and  redness, 
are  absent.     Similarly  in  acute  infections  of  bone,  Latra-medullary  suppura- 


A  TEXTBOOK  OF  SURGERY 

tion  is  indicated  in  the  early  stages  only  by  exquisite  tenderness  over  the 
seat  of  infection,  high  fever,  rigors,  sweats,  and  delirium.  It  is  most  import- 
ant in  such  cases  to  recognize  thai  suppuration  has  taken  place,  and  that 
operative  interference  is  urgently  indicated  some  hours  or  days  before  local 
redness,  swelling,  and  fluctuation  have  made  their  appearance.  It  will 
thus  be  clear  that  a  great  part  of  the  diagnosis  of  abscess  formation  depends 
rather  on  the  general  intoxication  that  is  taking  place  than  from  the  presence 
of  the  abscess  itself,  and  in  general  it  may  be  stated  that  an  abscess  is  not 
of  so  much  importance  from  its  local  effects  as  from  the  general  effects 
produced  by  the  toxins  secreted  by  the  infecting  organisms.  To  sum  up. 
tjie  sudden  appearance  of  a  tender  focus  with  severe  general  symptoms, 
e.g.  fever,  rigors,  sweats,  constipation,  vomiting,  delirium,  suggest  an  acute 
infection,  probably  suppurative  in  nature  (possibly  gangrenous).  A  know- 
ledge of  local  pathology  (of  bone,  gall-bladder,  appendix,  &c.)  will  help  to 
decide  the  probable  condition  and  decide  whether  operation  is  urgently 
needed.  Superficial  acute  abscesses  are  self-evident  from  the  foregoing 
description. 

The  above  description  applies  to  acute  abscesses.  In  chronic  or  cold 
abscess  the  diagnosis  may  often  be  delayed,  if  the  abscess  is  deep  seated. 
since  pain  and  tenderness  are  often  slight  or  absent,  and  the  patient  may 
present  himself  with  large  fluctuating  swelling.  In  such  a  case  the  diagnosis 
of  a  cold  abscess  will  have  to  be  made  from  other  cystic  conditions. 

The  position  of  the  swelling  will  be  of  assistance.  Thus  in  some  regions 
cystic  swellings,  other  than  cold  abscesses,  are  very  common,  e.g.  in  the 
tunica  vaginalis,  the  breast,  the  mid  line  of  the  spine,  &c,  and  such  condi- 
tions as  hydrocele,  cystic  disease  of  the  breast,  meningoceles,  &c,  must 
be  excluded  before  a  cold  abscess  is  diagnosed.  In  other  cases  cold  abscess 
will  be  found  by  the  surgeon  in  subjects  where  they  are  likely  to  occur  by 
careful  inspection  at  regular  intervals  as,  for  example,  psoas  or  retro- 
pharyngeal abscess  in  spinal  caries.  A  cystic  swelling,  developing  quietly 
and  painlessly  in  a  situation  where  other  cystic  swellings  are  uncommon, 
especially  if  in  conjunction  with  other  disease  likely  to  cause  such  a  condi- 
tion, such  as  tuberculosis  of  the  hip  or  spine,  or  where  lymphatic  glands 
are  abundant,  will  almost  certainly  prove  to  be  a  cold  abscess.  If  occurring 
where  other  cysts  are  common,  e.g.  the  breast,  difficulty  may  be  found  in 
settling  the  matter,  but  the  onset  and  previous  history  will  help,  viz.  as 
to  whether  cystic  from  the  outset,  as  in  true  cysts,  or  commencing  as  a  solid 
and  later  becoming  soft  and  fluctuating  as  in  an  abscess  ;  chronic  infection 
of  lymph-glands  and  later  involvement  of  the  skin  in  cold  abscesses  will 
decide  definitely.  Finally  such  simple  tests  as  that  for  translucency  will 
avoid  confusion  with  translucent  swellings  as  hydroceles,  meningoceles, 
cystic  hygromas,  &c.  A  cystic  swelling  of  recent  development  occurring 
in  a  situation  where  other  cysts  are  rare,  is  more  likely  to  be  a  cold  abscess 
than  any  other  thing. 


TREATMENT  OF  SUPPURATION  37 

COURSE 

In  most  instances  an  acute  abscess  tends  to  increase  in  size  and  finally 
burst  on  the  surface  or  into  some  hollow  cavity,  as  intestine,  rectum,  bladder, 
pharynx,  bronchus,  peritoneum,  pleura,  &c.  In  some  instances  the  infection 
is  inhibited  by  the  tissue  secretions  and  the  pus  absorbed,  and  healing  by 
granulation  takes  place,  especially  if  the  main  focus  be  removed.  This 
applies  principally  to  the  peritoneum,  which  has  the  greatest  power  of  any 
tissue  in  controlling  infections. 

Cold  abscesses  also  tend  to  spread  and  burst  as  above.  Such  abscesses 
have  a  way  of  following  along  fascial  planes  and  muscle  sheaths,  e.g.  the 
psoas,  and  tend  to  gravitate  downwards  ;  for  this  reason  the  term  "  gravita- 
tion abscess  "  is  sometimes  applied  to  them.  But  in  a  considerable  number 
of  these  cases  if  placed  under  favourable  conditions,  such  as  local  rest, 
generous  diet,  the  infection  may  become  stayed  and  the  pus  slowly  be 
absorbed,  being  replaced  by  slowly  cicatrizing  granulation  tissue,  often 
mixed  with  a  deposit  of  lime  salts  (calcification). 

TREATMENT  OF   SUPPURATION 

(1)  Acute  Abscess.  This  consists  briefly  in  free  opening  of  the  abscess, 
removing  infective  material,  foreign  bodies,  or  hopelessly  damaged  tissues, 
e.g.  a  gangrenous  appendix,  and  draining  the  abscess  cavity.  In  very  few 
cases  is  it  reasonable  to  wait  for  the  remote  possibility  of  absorption  of  the 
pus.  The  absorption  of  pus  from  the  anterior  chamber  of  the  eye  is  often 
instanced  as  an  example  of  suppuration,  which  can  be  allowed  to  become 
absorbed.  This  effusion  is,  however,  not  pus  in  the  strict  sense,  since 
although  it  is  a  turbid  fluid  containing  leucocytes,  there  are  no  organisms 
present  in  most  cases,  the  fluid  being  sterile.  In  some  instances  intra- 
peritoneal collections  of  pus  will  become  absorbed,  but  it  is  far  safer  in  most 
cases  of  acute  abscess  to  evacuate  the  pus  as  soon  as  it  is  diagnosed.  Formerly 
it  was  considered  correct  to  apply  hot  dressings  (fomentations)  or  cooling 
lotions  for  some  while  over  abscesses  before  opening  them  or,  as  it  was  called, 
allowing  them  to  "  ripen."  Such  teaching,  though  doubtless  beneficial 
in  the  case  of  cheese,  is  most  pernicious  when  applied  to  abscesses,  and  such 
symptomatic  treatment  is  only  justifiable  where,  as  regards  an  inflamed  focus, 
there  is  uncertainty  as  to  whether  suppuration  has  taken  place.  As  soon 
as  suppuration  is  diagnosed  the  pus  should  be  allowed  to  escape,  and  where 
uncertain  as  to  the  character  of  the  inflammation  and  where  symptoms  are 
severe,  or  the  possibilities  of  spreading  infection  are  very  dangerous,  as 
in  the  appendix,  mastoid,  or  acute  infections  of  bone,  it  will  be  wiser  to 
explore  by  open  incision  than  to  wait  till  diagnosis  is  certain.  Delays  are 
dangerous  in  the  treatment  of  acute  suppuration.  The  opening  made 
should  be  at  least  large  enough  to  ensure  free  drainage,  and  in  many  cases 
considerably  larger  to  permit  of  removal  of  diseased  structures  connected 
with  the  abscess  or  causing  it,  as  a  pyosalpinx,  inflamed  appendix.  &c.  Where 
the  abscess  is  in  close  proximity  to  important  structures,  such  as  large 


A  TEXTBOOK  OF  SURGERY 

sis,  and  the  anatomical  relations  are  disturbed  by  associated  swelling 
and  oedema,  the  method  of  Hilton  is  very  useful.  This  consists  in  opening 
tbe  skin  and  superficial  structures  with  the  knife,  and  then  pushing  blunt- 
pointed  forceps  into  the  mass,  opening  them  and  pulling  them  out  again, 
thus  making  a  Large  opening  by  blunt  violence,  and  running  very  little  risk 
of  piercing  or  tearing  the  tough  vessel  walls  or  nerves.  For  this  purpose 
sinus  forceps  are  good,  but  ordinary  Spencer-Wells  pressure  forceps  are 
better,  because  blunter  and  still  less  likely  to  damage  important  structures. 
A  gloved  finger  is  next  inserted  and  the  cavity  explored  for  foreign  bodies, 
diseased  tissues,  or  extensions  of  the  cavity  in  pockets,  and  a  large  tube 
inserted. 

The  question  of  removal  of  such  matters  as  dead  bone,  calculi,  or  diseased 
structures  is  considered  under  the  diseases  of  special  parts.  The  drainage- 
tube  is  left  in  position  from  two  to  four  days  unless  there  are  large  vessels  in 
close  proximity,  when  it  should  be  shortened  after  twenty-four  hours  so  as 
only  just  to  reach  the  abscess  cavity,  lest  necrotic  ulceration  of  the  vessels 
and  secondary  luemorrhage  take  place.  In  a  few  days  the  discharge  of  the 
abscess  will  alter  from  pus  to  sero-pus,  and  finally  clear  serum,  the  flow 
of  which  may  be  increased  by  application  of  warm  dressings  (fomentations) 
when  the  inflammation  is  superficial,  or  by  the  use  of  suction  apparatus, 
since  the  serum  has  a  beneficial  effect  in  destroying  infective  organisms, 
and  thus  promoting  healing.  In  addition,  a  foul  abscess  may  be  washed  out 
with  antiseptics.  Unless  complications  are  present  it  will  seldom  be  neces- 
sarv  to  retain  a  drainage-tube  for  more  than  a  week,  often  much  less,  the 
time  varying  with  the  condition  of  the  abscess,  as  indicated  by  pain,  swelling, 
the  character  of  the  discharge  and  the  general  signs,  fever,  &c.  Where 
large  vessels  are  exposed  it  will  often  be  wiser  to  dispense  with  the  drainage- 
tube  altogether,  but  enlarge  the  superficial  incision  and  pack  the  cavity 
lightly  with  sterile  gauze,  or  make  a  counter- opening  for  the  tube  in  some 
other  situation  to  avoid  the  vessels. 

Diffuse  suppuration,  such  as  is  met  with  in  the  subcutaneous  tissues 
(cellulitis),  in  bone  (periostitis,  osteomyelitis),  &c,  is  dealt  with  by  incisions 
and  drainage,  as  will  be  described  later  under  the  sections  on  Cellulitis, 
Bone  Diseases,  &c. 

Suppuration  from  mucous  surfaces  is  treated  by  lavage  with  weak 
antiseptics  or  astringents,  e.g.  protargol,  sulphate  of  zinc,  biniodide  or 
oxycyanide  of  mercury,  sanitas,  peroxide  of  hydrogen,  &c,  and  will  be 
further  discussed  under  Urethritis,  &c.  Similar  irrigation  is  often  suitable 
for  foul  abscess-cavities,  and  in  some  cases  of  suppuration  inside  natural 
cavities,  e.g.  empyema  of  the  antrum  of  Highmore. 

Moreover,  in  such  cases  administration  of  vaccines  prepared  from  the 
infecting  organism  is  often  worth  a  trial. 

TREATMENT  OF  COLD   ABSCESS 

\s  these  affections  have  more  tendency  to  spontaneous  healing,  operative 
treatment  is  less  urgent.     Thus  some  cases  may  be  placed  under  favourable 


ULCERATION.    SINUS  39 

conditions  as  regards  local  rest,  good  feeding,  &c,  and  watched.  Early- 
cases  of  psoas  abscess  come  into  this  category,  and  under  such  treatment 
the  abscess  may  be  converted  into  fibrous  and  calcareous  material.  Such 
treatment,  however,  needs  time,  and  where  the  abscess  is  easily  reached 
by  operative  measures  these  should  be  adopted.     Such  measures  consist  of : 

(a)  In  aspirating  the  contents  of  the  abscess  once,  or  repeatedly  with 
a  fine  needle.     (See  Tuberculosis.) 

(b)  In  opening  the  abscess  freely,  removing  the  pus  and  the  granulation 
tissue  lining  the  cavity  thoroughly,  and  allowing  the  cavity  to  collapse 
if  the  abscess  is  in  soft  tissues,  or  if  in  bone  replacing  the  abscess  with  some 
form  of  bone  "  stopping  "  as  detailed  in  the  section  on  Disease  of  Bones. 

(c)  In  some  instances  the  abscess  may  be  removed  entire,  e.g.  in  the 
case  of  suppurating  tuberculous  glands,  before  they  have  become  too 
adherent  to  surrounding  tissues. 

LOCAL  SEQUELS  OF  SUPPURATION,  ULCERATION,  SINUS, 
FISTULA,  GANGRENE 

Ulceration,  and  Ulcers.  These  terms  are  not  used  in  quite  the 
same  sense  and  may  lead  to  some  confusion.  By  "ulceration"  is  meant 
progressive  destruction  of  tissue  by  molecular  disintegration,  i.e.  it  is  allied 
to  or  forms  part  of  the  changes  described  as  taking  place  in  the  formation 
of  an  abscess,  and  is  the  antithesis  to  "gangrene"  or  "sloughing,"  where 
the  tissues  are  destroyed  wholesale. 

It  will  thus  be  seen  that  the  enlargement  of  an  abscess  by  gradual 
destruction  of  the  surrounding  tissues  is  a  process  of  ulceration. 

Ulceration  takes  place  on  the  surface  or  in  the  depths  of  the  tissues. 
Thus  we  may  have  ulceration  of  the  skin  or  mucous  membranes,  following 
on  inflammation,  or  it  may  occur  in  the  interior,  as  in  the  ulceration  of  or 
erosion  of  the  cartilage  of  joints,  or  the  intima  of  blood-vessels  whether 
from  inflammatory  or  degenerative  processes. 

The  term  ulcer  is  applied  to  a  breach  in  the  surface  of  the  body  or  of 
some  internal  cavity,  intestine,  joint,  artery,  &c.  Such  a  breach  is  filled 
with  some  attempt  at  repair,  in  the  shape  of  the  results  of  inflammatory 
reaction,  with  more  or  less  successful  production  of  granulation  tissue  and 
cicatrization.  Suppuration  and  ulceration  are  closely  allied  rrocesses. 
The  destruction  of  tissues  in  suppuration  and  abscess  formation  is  by  the 
process  of  ulceration,  and  if  an  abscess  destroys  the  tissues  and  reaches  the 
surface,  bursting  there,  it  may  be  regarded  as  a  surface  or  open  ulcer,  but 
while  still  surrounded  by  the  tissues  as  a  closed  ulcer.  The  causes  and 
changes  in  ulceration  and  ulcers  will  be  further  discussed  in  the  section  on 
Degenerations  and  Xecroses,  when  it  will  be  seen  that  ulceration  and  ulcers 
may  occur  quite  apart  from  inflammation  and  suppuration. 

SINUS  AND  FISTULA 

Where  a  burst  abscess  remains  widely  open  the  term  ulcer  is  often  used  to 
denote  the  resulting  breach  in  the  surface,  but  more  often  the  opening  will 


K)  A  TEXTBOOK  OF  SURGERY 

be  a  narrow  channel,  and  the  terms  "sinus"  and  "fistula  "  are  employed, 
A  sinus  is  a  narrow  channel  usually  lined  with  granulation  tissue  leading 
from  the  surface  into  the  deeper  tissues.  The  surface  on  which  a  sinus 
opens  may  be  the  skin  ot  some  cavity.  e.g.  rectum,  mastoid-antrum,  &c. 
Such  an  opening  usually  results  from  the  bursting  ot  opening  of  an  absi 
which  for  some  reason  will  not  heal  up  entirely. 

A  sinus  is  in  fact  a  narrow,  deep  ulcer  with  a  small  opening  on  the  surface, 
and  may  result  from  other  forms  of  ulceration  than  suppuration,  such  as 
that  found  in  malignant  growths.  A  fistula  is  a  similar  opening  existing 
between  the  surface  and  some  hollow  cavity,  such  as  the  intestine,  pharynx, 
trachea,  or  a  joint.  Fistula'  may  also  occur  between  two  hollow  viscera. 
e.g.  the  gall-bladder  and  intestine:  the  well-known  gastrojejunostomy  is 
an  example  of  a  fistula  made  for  curative  purposes. 

The  terms  sinus  and  fistula  are  often  used  loosely  the  one  for  the  other. 
The  causes  of  persistence  of  sinuses  or  fistulous  tracts  are  : 

(or)  The  presence  of  foreign  bodies  in  the  depths,  such  as  bullets,  pieces 
of  clothing,  sponges,  swabs,  dead  bone,  or  other  dead  or  dying  tissue. 

(b)  Some  constant  source  of  reinfection,  which  may  be  from  the  skin. 
if  asepsis  in  dressing  a  wound  is  not  maintained,  or  from  some  internal 
organ  as  when  fa?ces  obtain  access  to  the  internal  opening  of  a  fistula  in 
ano.  or  owing  to  retention  of  products  of  inflammation  owing  to  insufficient 
drainage. 

(c)  Where  the  infecting  organism  is  only  with  difficulty  destroyed 
by  the  tissues  as  in  the  case  of  the  tubercle  bacillus. 

(d)  Epithelisation  of  the  sinus  ;  naturally,  if  epithelium  grows  down, 
covering  the  walls  of  a  sinus,  healing  is  impossible  till  it  is  removed. 

(c)  Over-cicatrization  of  the  walls  of  the  sinus,  causing  deficient  blood- 
supply  ;  this  impairs  the  nutrition  and  power  of  healing  of  the  lining  of 
granulation  tissue. 

(/)  Retaining  a  drainage-tube  or  gauze  packing  too  long  after  opening 
an  abscess.  In  practice  this  is  a  fairly  common  cause,  tending  to  keep  a 
sinus  open,  and  by  promoting  over-cicatrization  renders  the  walls  of  a 
sinus  stiff  so  that  they  do  not  readily  come  together  and  heal. 

Diagnosis.  This  is  simple,  an  aperture  discharging  pus  and  possibly  some 
secretion,  such  as  bile  or  frees,  will  be  noted,  while  the  thickened  track  of 
the  sinus  is  felt  through  the  skin  as  an  area  of  induration. 

Treatment.  Removal  of  the  cause,  where  possible,  is  essential.  This 
involves  free  opening  up  of  the  sinus  and  removal  of  such  things  as  foreign 
bodies,  dead  bone,  tuberculous  glands,  a  disorganized  kidney,  &c. 

Where  there  is  certainly  no  such  underlying  cause  the  sinus  walls  are 
freshened  by  curetting,  rendered  aseptic  with  pure  carbolic  and  the  cavity 
left  unpacked.  Often  simply  removing  a  gauze  plug,  which  the  too  con- 
scientious practitioner  has  been  ramming  in  for  some  weeks,  will  permit 
of  healing  in  a  few  days.  Such  treatment,  i.e.  curetting,  will  also  remove 
a  downgrowth  of  epithelium  from  the  interior  of  the  sinus  if  this  is  responsible 
for  its  persistence. 


TREATMENT  OF  SINUS 


41 


Producing  rest  of  the  part  by  immobilization  will  be  of  assistance  in 
some  cases,  especially  those  following  on  joint  or  bone  disease ;  thus  a 
sinus  resulting  from  bursting  or  opening  of  a  psoas  abscess  will  be  improved 
by  immobilizing  the  spine  on  a  Thomas's  splint.  In  other  cases  a  plaster 
casing  to  immobilize  the  affected 
joint  with  a  window  cut,  for 
dressing  the  sinus,  is  very  use- 
ful. 

Injection  of  Beck's  bismuth 
paste  (30  per  cent,  carbonate 
of  bismuth  in  vaseline)  is  often 
successful,  especially  in  tuber- 
culous sinuses,  and  always  worth 
a  trial.  The  sinus  is  rendered 
aseptic  and  the  paste  injected 
warm  and  molten  ;  it  becomes 
firmer  on  cooling  and  tends  to 
remain  in  the  sinus  (Fig.  6). 

Finally,  attempts  may  be 
made  to  improve  the  resistance 
of  the  tissues  with  vaccines 
made  from  the  organisms  found 
in  the  discharge  from  the  sinus. 

When  the  condition  is  defi- 
nitely "fistulous"  a  suitable 
plastic  operation  will  be-needed 
in  most  cases  (see  fistulas  of 
the  intestine  of  the  salivary 
ducts,  ureters,  &c).  It  will  be 
noted  that  fistulas  are  sometimes  established  in  the  course  of  surgical 
treatment,  as  when  a  colostomy  is  performed  to  relieve  intestinal  obstruc- 
tion, or  a  gastrojejunostomy  to  obviate  pyloric  stenosis. 


Fig.  6.     Skiagram  of  a  hip  after  filling  a  sinus 

with  bismuth  paste,  showing  relation  to  the  shaft 

of  the  bone  and  not  to  the  joint. 


SLOUGHING   AND   GANGRENE   OCCURRING   IN    THE   COURSE   OF 

SUPPURATION 

The  possibility  of  this  termination  of  inflammatory  reaction  has  been 
mentioned  as  the  extreme  type  of  degenerative  sequel.  It  will  be  more 
convenient  to  consider  changes  of  this  nature  in  the  next  section,  amongst 
degenerations  and  necroses,  since  there  are  several  other  conditions  in  the 
train  of  which  these  more  severe  and  lethal  tissue-changes  occur. 


CHAPTER  V 

DEGENERATIONS   AND   NECROSES     ULCERS   AND   GANGRENE 

Cell-degenerations  :  Varieties  of  Degeneration  :  Ulcers  :  Anatomy  and  Causes 
of  Ulcers  :  Sealing,  Spreading,  and  Stationary  Ulcers  :  Treatment  of  Ulcers  : 
Skin  Grafting  :  Special  forms  of  Ulcers. 

Gangrene  :  Dry  and  Moist  Grangrene  :  Clinical  Appearances  :  Traumatic 
Gangrene  :  Nontraumatic  Vascular  <  fangrene  :  Infective  ( langrene. 

In  the  previous  sections  we  have  considered  the  reaction  of  the  tissues  to 
adverse  circumstances,  in  which  the  victory  was  to  a  large  extent  with  the 
defending  organism  ;  at  the  same  time,  in  the  latter  part,  noting  the  partial 
or  complete  failure  of  this  reaction  in  certain  cases.  We  now  have  to  discuss, 
in  more  detail,  conditions  in  which  the  response  is  small  or  absent,  and  the 
tissues  retrograde  in  various  ways  or  even  undergo  the  last  tragedy  of  living 
matter,  death. 

regenerative  processes  are  numerous  and  diverse,  in  many  in- 
stances not  coming  into  practical  surgery  :  nevertheless  a  short  considera- 
tion of  these  will  be  of  service  in  supplying  a  key  to  the  real  meaning  of 
those  conditions  with  which  the  surgeon  is  particularly  interested,  viz. 
ulceration  and  gangrene. 

The  more  important  causes  of  tissue  and  cell-degenerations  are  : 

(1)  Disuse  and  Over-use.  The  degeneration  of  tissues  from  disuse  is 
well  instanced  by  the  wasting  of  a  limb  controlled  by  a  splint.  The  degenera- 
tion is  a  simple  atrophy  or  diminution  in  size  and  function  of  the  cells,  and 
noted  clinically  in  the  flabby  skin,  weak,  wasted  muscles,  and  the  thinned. 
rarefied  bones,  which  last  form  a  marked  contrast  in  radiograms  to  those 
on  the  sound  side.  Over-use  leads  to  a  primary  hypertrophy  as  seen  in 
the  limbs  of  athletes  and  those  whose  occupations  are  laborious.  The 
thickened  bladder  or  intestine,  where  there  is  obstruction  to  these  organs, 
and  the  enlarged  heart  of  valvular  disease,  are  further  examples  of  this 
change.  Later  this  hypertrophy  changes  to  atrophy,  as  found  in  the  arms 
of  blacksmiths  after  long  exercise  of  their  functions  and  in  the  dilatation 
of  tailing  hearts,  atony  of  the  bladder  from  prostatic  obstruction,  &c. 

(2)  Old  Age  is  responsible  for  atrophy,  well  seen  in  the  flabby,  wrinkled 
skin  and  weak  muscles  of  the  aged,  as  well  as  in  the  rarefied  hones  which 
render  fracture  of  the  femoral  neck  and  lower  end  of  the  radius,  so  common 
in  elderly  persons. 

(3)  Impairment  of  Blood-supply  alters  the  vital  activity  of  the  tissues 
supplied.  Thus  in  a  minor  degree  the  slowing  of  the  venous  circulation 
from  the  presence  of  varicose  veins  diminishes  the  tissue-reaction  to  irritants, 

42 


CELL-DEGENERATIONS  43 

and  eczema  or  ulceration  results,  so  commonly  seen  in  the  lower  part  of  the 
leg.  As  an  example  of  more  serious  interference  with  the  blood -supply, 
we  may  take  the  effect  of  cutting  off  the  blood-supply  to  a  loop  of  gut  by 
strangulation  at  the  neck  of  a  hernial  sac,  which  readily  leads  to  gangrene 
or  death  of  the  part  affected. 

(4)  Impairment  of  the  Nerve-supply  leads  to  atrophy  and  degeneration 
of  the  muscle  supplied.  Alterations  in  the  skin  may  also  be  noted  (described 
in  detail  in  the  section  on  Nerves),  such  as  ulcers  and  whitlows';  though 
whether  these  result  from  loss  of  "  trophic  "  influence  or  simply  because 
injuries  are  not  appreciated,  and  so  allowed  to  continue  acting,  is  uncertain. 

(5)  Degenerations  resulting  from  the  action  of  poisons  are  common  and 
vary  with  the  special  poison  present.  All  sorts  of  noxious  agents  are 
included  under  this  term,  such  as  mercury,  alcohol,  phosphorus,  and  many 
other  drugs  or  chemicals  used  in  arts  or  trades.  More  important  from  a 
surgical  standpoint  are  the  infective  organisms  and  their  poisonous  or  toxic 
excretions,  which  lead  to  many  different  degenerative  changes,  as  cloudy 
swelling,  coagulative  and  colliquative  necrosis,  amyloid  and  calcareous  de- 
generation, &c. 

VARIETIES   OF   DEGENERATION 

(1)  Atrophy  implies  simply  diminution  of  the  size  of  the  cells  and 
loss  of  intercellular  substance  in  the  atrophied  part. 

(2)  Fatty  Degeneration  may  be  an  excessive  storing  of  fat  in  cells  without 
loss  of  cell  substance  (fatty  infiltration)  or  atrophy  of  cells  with  deposit 
of  fat,  i.e.  alteration  of  the  cell  protoplasm  into  fat  (proper  fatty  degenera- 
tion). This  condition  is  often  the  result  of  poisons,  such  as  alcohol,  phos- 
phorus, and  is  found  more  in  diseases  which  are  considered  medical.  Cutting 
of  the  nerve-supply  of  muscles  or  other  interference  with  nerves  is  also 
responsible,  as  in  the  fatty  degeneration  of  muscles  whose  nerve-supply 
has  been  destroyed  by  anterior  poliomyelitis. 

(3)  Hydropic  Degeneration  or  swelling  of  cells  with  fluid  (oedema  of 
cells)  results  from  the  action  of  irritants  and  may  be  instanced  by  the  forma- 
tion of  blebs  under  the  epidermis  from  burns  and  scalds  (this  condition  is 
sometimes  called  colliquative  necrosis). 

(4)  Granular  Degeneration  or  Cloudy  Swelling  consists  in  the  deposit  of 
albuminoid  granules  in  the  cell,  resulting  from  destruction  of  the  cell  proto- 
plasm and  causing  obscuration  of  the  cell  structure  and  impaired  staining 
reactions  of  the  cell  body  and  nucleus.  This  condition  is  especially  found 
as  a  result  of  the  action  of  infective  organisms.  A  similar  condition  is 
found  in  nerves  below  a  section.  Necrosis  of  the  degenerating  cells  often 
follows  this  condition. 

(5)  Amyloid  Degeneration  is  the  infiltration  of  cells  with  an  albuminoid 
substance  known  as  "  amyloid,"  "  waxy,"  or  "  lardaceous  "  material,  which 
has  the  property  of  staining  blue  with  iodine  and  sulphuric  acid.  Amyloid 
degeneration  is  caused  by  certain  toxins  usually  resulting  from  prolonged 
suppuration,  and  affects  especially  the  walls  of  small  blood  vessels  of  the 


ll  \  TEXTBOOK  OF  SURGERY 

liver,  spleen,  and  kidney,  causing  those  organs  to  become  larger  and  firmer 

than  usual,  and  to  appear  on  section  shining  and  translucent   like  raw 
bacon,  whence  the  name  "  lardaceous  disease." 

(ii)  Glycogenic  Degeneration  or  excessive  infiltration  with  glycogen,  found 
mostly  in  various  kinds  of  new  growth,  of  which  the  renal  mesothelioma 
or  Grawitz  tumour  is  a  good  example. 

(7)  Colloid  I  ition  or  deposit  of  colloid  material,  resembling  that 
found  normally  in  the  acini  of  the  thyroid  gland,  is  found  mostly  in  certain 
cancel-. 

(8)  ( Calcareous  Degi  neration  or  infiltration  with  carbonates  and  phosphates 
of  calcium.  This  occurs  as  a  senile  change  in  the  calcification  of  cartilage 
and  arteries,  and  in  chronic  inflammatory  foci  where  other  degenerations 
are  also  taking  place,  as  in  old-standing  tuberculous  lesions,  and  in  tumours, 
especially  sarcomas.  The  formation  of  calculi,  whether  uratic  or  phos- 
phatic,  &c,  is  allied  to  this  form  of  degeneration. 

(9)  Pigmentary  Infiltration  is  often  a  resist  of  inflammatory  reactions. 
e.g.  sunburn,  and  the  pigmentation  associated  with  the  eczema  and  ulceration 
following  on  varicose  veins. 

(10)  Necrosis  or  the  death  of  tissues  and  cells.  This  change  is  allied  to 
granidar  degeneration  or  cloudy  swelling  ;  the  cells  becoming  granular, 
losing  their  staining  reactions,  and  finally  disintegrating.  The  termination 
of  necrosis  varies  thus  : 

(a)  ( 'oagulative  Necrosis.  In  this  condit  ion  the  dead  tissues  remain  solid, 
and  are  gradually  replaced  by  absorption  from  invading  cells  and  conversion 
into  fibrous  tissue.  Examples  of  this  are  :  anaemic  infarcts  of  the  kidney 
from  embolism,  ischsemic  contracture,  which  is  really  anaemic  necrosis 
of  the  muscles  of  the  arm  following  over-tight  splinting  (Volckmann's 
ischsemic  contracture),  and  the  sloughs  in  syphilitic  gummata.  Gangrene  is 
a  variety  of  coagulative  necrosis,  where  after  the  death  of  the  tissues  these 
become  decomposed  by  putrefactive  organisms. 

(/;)  Colliquative  Necrosis.  Two  different  conditions  are  confused  under 
this  term:  (I)  Liquefaction  by  infective  (pyogenic)  organisms,  acting  on 
desl  royed  tissues  as  in  the  formation  of  abscesses.  (2)  Autogenous  liquefac- 
tion of  necrotic  areas  as  in  the  softening  of  atheromatous  masses  in  the  walls 
of  blood-vessels  or  in  infarcts,  i.e.  areas  rendered  anaemic  by  occlusion  of  the 
vessels  of  supply  as  in  "red  softening  "  of  the  brain  ;  a  similar  liquefaction 
occurs  in  tumours,  such  as  uterine  fibroids,  whore  it  is  known  as  "'necrobiosis." 

(r)  Case'il'mn  is  a  form  of  coagulative  necrosis  often  found  in  tuberculous 
h'sions  :  the  dead  mass  becoming  yellowish,  soft  and  friable,  and  later 
often  liquefies  and  forms  chronic  pus,  but  occasionally  remains  a  solid  tough 
mass,  as  is  usually  the  case  where  a  syphilitic  gumma  undergoes  necrosis. 

(</)  Fat  Necrosis  is  a  special  type  of  necrosis  produced  by  the  action  of 
pancreatic  ferments,  the  characteristic  yellowish-white  patches  being  formed 
of  a  combination  of  calcium  with  fatty  acids  in  the  necrosing  tissues. 


ULCERS  45 

ULCERS    AND   GANGRENE 

The  conditions  known  as  ulcers  and  gangrene  are  associated  with  and 
due  to  some  or  other  of  the  above-described  necrotic  changes  in  the  tissues. 
Although  usually  separated  in  works  on  surgery,  these  conditions  have 
much  in  common.  Thus  an  ulcer  is  often  not  the  result  of  process  of  ulcera- 
tion, i.e.  piecemeal  destruction  of  tissues,  but  rather  of  gangrene.  For 
example,  conditions  known  as  ulcers,  such  as  those  following  burns  or 
sloughing  of  gummata,  are  the  result  of  localized  gangrene  or  necrosis,  and 
not  of  ulceration  ;  while  rapidly  advancing  ulceration,  such  as  that  described 
as  phagedenic,  may  equally  well  be  regarded  as  a  process  of  gangrene  on  a 
small  scale.  An  ulcer  is  a  condition  or  state  of  tissues,  while  gangrene  and 
ulceration  are  processes  which  may  lead  to  the  formation  of  ulcers. 

ULCERS 

An  ulcer  is  an  open  sore  or  raw  place  on  the  surface  of  the  body  or  of 
one  of  the  body  cavities,  is  due  to  destruction  of  the  surface  covering, 
and  may  be  in  varying  conditions  of  (a)  advance  or  spread  ;  (b)  repair  or 
diminution  in  size,  or  (c)  in  an  intermediate  state,  when  it  is  described  as 
a  stationary  or  chronic  ulcer. 

The  process  of  spread  is  similar  to  that  described  under  the  necrotic 
sequela?  of  inflammation.  Repair  is  by  the  formation  of  granulation  tissue, 
which  later  becomes  fibrous  and  over  which  the  surface-covering  of  epithe- 
lium grows  from  the  edges  of  the  ulcer.  Spread  of  ulcers  is  by  gradual 
destruction  of  the  tissues  at  the  edge  (ulceration),  less  often  by  gross  destruc- 
tion or  sloughing,  and  varies  in  rapidity  with  the  resistance  of  the  tissue  to 
the  causal  agent. 

ANATOMY   OF    ULCERS 

The  following  parts  of  an  ulcer  are  to  be  recognized  : 

(1)  The  edge  or  place  where  the  normal  skin  or  mucosa  changes  into 
the  raw  surface,  and  which  may  be  sharply  cut,  sloping,  everted  and 
"  rolled,"  overhanging,  &c. 

(2)  The  margin  or  surrounding  tissues,  which  may  be  unaltered,  or  red 
and  inflamed,  thick  and  cedematous,  hard  and  infiltrated,  &c. 

(3)  The  floor,  which  may  consist  of  fine  regular  granulations,  coarse 
flabby  ansemic  granulations,  sloughy  masses,  callous  fibrous  tissue  with 
few  granulations,  &c. 

(4)  The  base  or  the  tissues  below  the  floor,  and  which  cannot  be  seen 
but  only  felt ;  this  may  be  soft  and  pliable,  or  hard,  dense,  infiltrated,  and 
adherent  to  surrounding  tissues,  such  as  bone,  fascia,  &c. 

(5)  The  discharge,  from  the  surface,  which  may  be  abundant  or  scan  I  y, 
serous,  purulent,  foul,  blood-stained,  &c. 

Ulcers  may  be  classified  according  to  their  condition  or  according  to 
their  main  underlying  causes. 


i<; 


A  TK.YI  BOOK   OF  SURGERY 


CAUSES   OF    ULCERS 

The  formation  of  ulcers  may  be  due  to  some  one  definite  cause,  as  infec- 
tion with  the  tubercle  bacillus,  the  spirochaete  of  syphilis,  staphylococcus 
aureus,  a  malignant  new  growth,  or  Bevere  injury,  as  crushes,  burns,  scalds. 

1  ommonly,  there  is  some  primary  cause,  wounds,  burns,  crushes,  or  abla- 
tion of  tissue,  associated  with  a  general  stale  which  lowers  the  resistance 
of  the  tissues,  such  as  anaemia,  scurvy,  under-feeding,  ot  Borne  local  condition 
as  impairment  of  blood-  and  uerve-supply,  further  complicated  in  many  cases 


with    infection    by    some   pyogenic    organism 


Fro.  7.     Cancer  of  the  penis  in  the  form  of  a  callous 

ulcer. 


the  blood-supply,   if    besl    and 


Aseptic  ulceration,  in  a 
bacteriological  sense,  is 
seldom  attained,  excepl 
in  the  interior  of  closed 
organs,  such  as  blood- 
vessels or  joints;  still  by 
aseptic  measures,  in  many 
cases,  traumatic  ulcera- 
tion can  be  rendered 
practically  aseptic.  As 
there  may  be  several 
causes  responsible  in  any 
given  ulcer,  for  purpose 
of  classification  we  take 
the  more  i mp o rt a n t 
causes,  but  in  treatment 
it  is  well  to  remember 
that  all  possible  causes 
must  be  considered,  e.g. 
in  ulcers  due  to  varicose 
veins,  sepsis  is  an  impor- 
tant factor,  and  it  will 
be  necessary  to  diminish 
the  sepsis,  as  well  as 
speediest   results  are   to  be 


to   improve 

obtained. 

Ulcers  may  be  classified  according  to  cause  in  the  following  manner: 
(1)  Traumatic  ;  (2)  from  local  malnutrition  ;  (3)  from  general  malnutrition  ; 
(4)  from  infectious  ;   (5)  from  newT  growths. 

(1)  Traumatic  Ulceration.  There  are  many  varieties  of  ulcer  caused 
by  trauma,  but  all  have  this  in  common,  that  the  epithelium  over  the  area 
in  question  is  destroyed  down  to  the  dermis,  which  is  exposed  and  shows 
inflammatory  reaction  with  formation  of  granulations.  As  instances  we 
may  note  : 

(a)  Destruction  of  the  whole  epidermis  and  superficial  dermis  by  crushing 
violence,  either  immediate  or  from  the  destruction  of  vessels  supplying  the 
tissues.      In  most  such  cases  not  only  the  epidermis  but  all  the  dermis  is 


VARIETIES  OF  ULCERS  47 

destroyed  ;  the  destroyed  tissues  form  a  slough,  which  becomes  separated, 
leaving  a  raw  area,  which  if  kept  under  relatively  aseptic  conditions  will 
heal  by  the  process  described  above  as  "  healing  by  granulation." 

(b)  The  destruction  of  superficial  tissues  by  burns,scalds.  X-rays,  caustics, 
the  pressure  of  splints  or  prolonged  pressure  by  resting  in  bed  in  one 
position  (bed-sores),  are  further  examples  of  such  traumatic  causation  of 
ulcers. 

(2)  The  Formation  of  Ulcers  from  Local  Malnutrition.  This 
may  be  due  to  disturbance  of  the  vascular  or  nervous  supply,  (a)  Of  those 
due  to  deficient  venous  return,  the  ulcers  associated  with  varicose  veins 
of  the  leg  furnish  the  best  example.  Less  common  are  ulcers  arising 
from  deficient  arterial  supply,  but  the  ulceration  of  fingers  and  tips  of  the 
ears  in  Raynaud's  disease  nun-  be  noted  :  more  often  the  destruction,  where 
arterial  supply  is  in- 
volved, is  of  more  gross 
nature,  and  such  cases  >>— -*- 
are  classed  under  the  $^~^0&O)Cii ■ 
term  gangrene.  •'  ,  .  •  jgft > •'• ':■;%'■?'  :,';£ 

(b)   Deficient     ner- 
vous    supply     is    well  .  -  V*               .V-^**"*"^'-'  05 
shown  in  parts  of  limbs  -  "  5? 
deprived    of    sensation 

bv      injuries      to       the  1|,;S-     Diagrammatic  section  of  ulcer  (magnified).  Malignant 

•*                       .    .  ulcer.     Note  rolled  edge  and  epithelial  infiltration  of  floor. 

nerves  of  supply,  giving 

rise  to  blebs,  pustules,  and  later  ulceration,  or  in  such  diseases  as  tabes,  in 
which  "  perforating  ulcer  "  of  the  sole  of  the  foot  is  often  seen,  developing 
from  inflamed  corns.  How  much  of  such  ulcer  formation  is  due  to  loss  of 
trophic  influence  of  the  affected  nerves,  and  how  much  to  repeated  and 
unnoticed  injury  and  infection,  is  disputed. 

(3)  As  instances  of  ulcers  arising  from  general  malnutrition,  those  found 
in  scurvy  and  chronic  mercurialism  may  be  instanced. 

(4)  Infective  Ulcers.  A  great  variety  of  ulcers  is  included 
under  this  heading,  e.g.  from  pyogenic  infections  of  all  sorts,  the  tubercle, 
glanders,  actinomycosis  organisms,  and  the  spirochaete  of  syphilis. 

(5)  Malignant  ulcers  from  breaking  down  of  superficial  new  growths 
form  a  very  distinct  group.     (Eigs.  7.  8.) 

CLASSIFICATION    OF    ULCERS   ACCORDING   TO   THEIR   CONDITION 

It  has  been  already  pointed  out  that  ulcers  may  be  (a)  healing,  (6)  spread- 
ing, or  (c)  relatively  stationary.  Sometimes  spreading  takes  place  in  one 
part  while  healing  is  going  on  at  another  ;  this  is  specially  found  in  gumma- 
tous and  rodent  ulcers. 

(a)  Healing  Ulcers.  This  condition  is  practically  synonymous  with 
""  healing  by  granulation  "  of  a  widely  open  breach  in  the  surface,  and  is 
seen  in  the  healing  of  burns  after  the  sloughs  have  separated,  after  the 
opening  of  superficial  pyogenic  abscesses  where  the  skin  over  the  abscess 


I- 


\  TEXTBOOK  OF  SURGERY 


Pig.  9. 

ulcer. 


Diagrammatic  section  of  ulcer  (magnified).    Healing 
Note  the  epithelium   stealing   over  the  floor  of  the 
ulcer. 


•  /iik  :''*$&'$s& 


has  been  destroyed,  or  in  the  healing  of  a  chronic  ulcer  which  has  been 
freshened  up  by  curetting  or  application  of  pure  carbolic,  &c.  'I  he  floor  of 
such  an  ulcer  is  covered  with  small,  even,  red,  healthy-looking  granulations 
with  but  slight  serous  discharge,  which  if  not  strongly  antiseptic  is  decidedly 
inimical  to  bacterial  growth.  The  edges  are  shelving,  owing  to  the  growth 
of  epithelium  over  the  granulating  surface.  The  growing  edge  of  epithelium 
appears  bluish  from  the  red  granulations  seen  obscurely  through;  further 
front  the  growing  edge  to  its  outer  side,  the  epithelium  is  hypertrophic 
and  heaped  up,  appearing  whitish  from  local  over-growth  and  failure  to 
desquamate.  The  margin,  i.e.  the  surrounding  skin,  is  normal  in  appear- 
ance :    redness  and  other  signs  of  inflammation  are  absent  to  macroscopic 

examination.  The  base 
of  such  an  ulcer  is  sofl . 
there  being  no  under- 
lying infiltration  or  ad- 
herence to  neighbouring 
tissues.  The  over- 
growing of  epithelium 
is  followed  by  the  ((in- 
version of  the  granula- 
tions, thus  covered  into 
fibrous  tissue  till  the 
whole  is  converted  into 
a  cicatrix  covered  with 
thin,  fine,  soft  epithe- 
lium, devoid  of  hair 
and  glands.  Thereare, 
however,  limits  to  the 
power  of  epithelium, 
in  thus  growing  over 
granulation  tissue, 
varying  with  age  and  personal  peculiarities  :  the  process  of  epithelisation 
may  cease  and  come  to  a  standstill,  the  ulcer  thus  becoming  stationary  or 
chronic.  This  failure  to  heal  over  is,  to  a  large  extent,  due  to  poor  blood- 
supply,  owing  to  the  formation  of  fibrous  tissue  in  the  deeper  parts  of  the 
granulating  surface,  which  in  contracting  blocks  the  blood-supply  and  thus 
cuts  off  the  nutrition  of  the  granulations  and  overlying  epithelium  (Fig.  9). 
(b)  Spreading  Ulcers.  These  are  due  to  the  inability  of  the  tissues 
to  deal  with  the  activity  of  the  causal  agent,  if  infective,  whether  from  the 
potency  of  this  or  the  local  or  general  impotence  of  the  tissues,  or  from  the 
advance  of  degeneration  in  a  new  grow7th.  The  appearance  of  such  an  ulcer 
varies  with  the  rapidity  with  which  it  is  extending  its  boundaries.  Where 
the  advance  is  slow  the  granulations  of  the  floor  are  less  regular  and  the 
discharge  less  clear  than  in  the  healing  type;  the  edges  are  not  shelving 
but  more  sharply  cut  out,  and  the  margins  and  base  show  some  degree  of 
hyperemia  and  infiltration  due  to  inflammation  or  new  growth.     Such 


. 


*»    -  .£s 


Fig.  10.    Diagrammatic  section  of  ulcer  (magnified).  Advanc- 
ing ulcer.     Note  the  slough  disintegrating  edge  and  floor. 


STATIONARY  ULCERS  49 

ulcers  form  a  transition  between  rapidly  spreading  and  the  stationary  type  of 
ulcer,  where  no  advance  is  appreciable.  The  rodent  and  the  gummatous  ulcer 
are  of  this  type.  Where  the  advance  is  somewhat  more  rapid  the  surroundings 
will  be  markedly  red  and  infiltrated,  and  the  base  adherent ;  the  edges  sharply 
cut,  perhaps  undermined  ;  small  sloughs  will  be  seen  covering  the  floor  and 
separating  from  the  edges  ;  the  discharge  is  sero-purulent  and  dirty,  mingled 
perhaps  with  sloughs  and  blood-stained  serum.  Such  conditions  are  described 
as  inflamed  ulcers,  and  these  are  painful ;  healing  ulcers  are  painless,  though 
often  the  seat  of  severe  itching.  When  the  progress  of  ulceration  is  still 
more  rapid  the  surrounding  tissues  will  be  swollen  and  oedematous,  dusky 
red  or  purple  in  colour,  and  the  edges  melt  away  rapidly  in  sloughs  ;  the 
discharge  is  foul,  turbid  serum,  often  blood-stained,  and  spread  is  rapid. 
A  good  example  is  a  spreading  ulcer  of  the  leg  due  to  varicose  veins.  The 
more  rapidly  spreading  ulcers  are  known  as  "  phagedenic  "  or  "  sloughing  "" 
ulcers,  and  occur  chiefly  on  the  penis,  from  syphilitic  infection  complicated  by 
pyogenic  organisms,  and 

in  the  mouth  and  vulva.    ^Ki\iJX^^\  r~rZr..,'^ .{VT?.- 

in  the  condition  known  -^ 

as  Noma  (Fig.  10). 

(c)  Stationary, 
Callous,  or  Chronic 
Ulcers.  In  these 
cases   the    size   of  the    ,,„-,.  .  ,      ,         ■<.  ,,    c,4  .. 

Fig.  11.     Diagrammatic  section  of  ulcer  (magnified).    Station- 
ulcer  alters  very  slowly;  ary  ulcer,  callous  type. 

often    in    such    ulcers 

very  slow  increase  is  taking  place,  by  fits  and  starts,  for  if  not  spreading 

healing  is  usual,  but  the  spread  is  so  slow  that  it  is  unnoticeable  after 

weeks  or  months  ;    or  healing  and  spreading  may  occur  in  turns,  leaving 

the  ulcer  in  statu  quo.     There  are  two  main  types  of  chronic  ulcer  : 

(1)  The  fibrous  or  callous  ulcer,  which  has  sharply  punched-out  edges, 
usually  firm  and  even  hard,  but  not  everted  or  "rolled"  as  in  malignant, 
advancing  ulcers.  The  base  is  infiltrated  and  fibrosed,  adherent  to  under- 
lying structures,  such  as  bone.  The  floor  is  glazed  and  very  barren  of  granula- 
tions ;  the  discharge  is  slight  and  sticky,  tending  to  form  crusts  and  scabs 
over  the  ulcer.  This  type  is  often  due  to  deficient  blood-supply,  as  in  the 
ulcers  consecutive  to  varicose  veins ;  over-contraction  of  the  fibrous 
tissue  in  the  base  of  a  healing  ulcer,  of  large  size,  may  cause  this  to  assume 
the  callous  form,  as  has  been  already  mentioned  ;  gummatous  ulcers,  less 
often  tuberculous  ulcers  {e.g.  of  the  tongue),  are  of  the  callous  variety. 
Chronic  ulcers  of  the  stomach  and  duodenum,  which  are  kept  up  by  constant 
irritation  of  hyperacid  gastric  juice,  may  also  be  instanced.  (Fig.  11.) 

(2)  The  hypertrophic  typo,  in  which  the  granulations  are  exuberant 
and  overgrown  ;  the  hypertrophy  of  granulations  prevents  the  epithelium 
from  readily  growing  over  them.  This  variety  is  common  in  ulcers  of 
traumatic  and  infective  origin,  and  is  due  to  local  irritation  of  a  minor 
character,  such  as  retention  of  discharges,  over-long  use  of  fomentations,  &c. 

r  4 


f?Z\  Y$)  f7)  (7r\  an 

O^^^r.liV:  ^)hm^m^  an 

-  ->V-;  ..^v.  "•*-•*  th. 

r     .•»  -*'>  <  %"  bi( 

•>'*''*  Rir 


50  A  TEXTBOOK  OF  si'RGERY 

Tuberculous  ulcers  arc  often  of  a  type  closely  allied  but  differing,  in  thai 
the  granulations  though  hypertrophic  are  anaemic  and  not  florid,  as  in  the 
case  of  the  "'  proud  flesh  "  of  the  ordinary  hypertrophic  ulcer.     (F'g.  12.) 
Other  varieties  of  chronic  ulcer  are  also  described. 
The  Weak  ulcer,  which  is  a  mixture  of  the  callous  and  hypertrophic  ; 
the  granulations  are  mostly  small  and  deficient   in  parts,  but  in  others 

enlarged    and    usually 

/"X    \VJ  /^J  '."'  anaemic;  there  is  sur- 

V  (x-J'li^n'i^'ftf  f^^^^^y^^-     rounding  inflammation 

7*&VM  and  some  induration  : 

the  discharge  is  tur- 
bid, but  spread  is  very 
slow.  These  are  prac- 
tically a  mild  variety 
Fig.  12.  Diagrammatic  section  of  ulcer  (magnified).  Station-  of  inflamed  ulcers  The 
ary  ulcer,  hypertrophic  type. 

term  Irritable  is  ap- 
plied to  some  ulcers  which  are  extremely  painful  and  tender  on  being  touched, 
presumably  from  the  presence  of  nerve  filaments  in  their  floor.  The  outer- 
side  of  the  ankle  in  women  is  a  favourite  situation  for  such  ulcers,  but  the 
best  example  is  the  small  ulcer  at  the  opening  of  the  anal  canal,  usually 
known  as  "  anal  fissure,"  and  which  in  many  instances  is  most  extraordinarily 
tender. 

RESULTS   OF   ULCERATION 

(1)  On  healing,  great  scarring  may  result  if  the  ulcer  is  of  large  size, 
e.g.  the  deformities  resulting  from  superficial  burns ;  the  scarring  of  the 
palate  and  pharynx  after  gummatous  ulceration :  of  the  oesophagus  after 
swallowing  corrosives  ;  hour-glass  stomach,  and  pyloric  stenosis  from  gastric 
and  pyloric  ulcers. 

(2)  "When  stationary  the  raw  surface  is  prone  to  infections,  thus  erysipelas 
not  infrequently  takes  origin  in  a  chronic  ulcer. 

(3)  Spreading  may  lead  to  very  serious  results.  Thus  large  vessels  may 
be  eroded,  causing  fatal  haemorrhage,  even  if  veins  are  opened  by  spread 
of  varicose  ulcers,  bleeding  will  be  severe  if  first  aid  is  not  prompt.  Spread 
of  gastric  and  pyloric  ulcers  may  occur,  with  great  rapidity,  with  perforation 
into  the  peritoneum,  rapidly  causing  fatal  peritonitis,  unless  surgical  measures 
be  speedily  adopted.  Finally,  in  cases  of  rapid  spread,  the  patient  may 
be  overwhelmed  by  the  severity  of  the  poisoning  from  the  toxins  produced 
by  the  infective  organism  which  causes  such  spread,  as  in  cancrum  oris  and 
noma. 

GENERAL  TREATMENT  OF  ULCERS 

The  first  aim  is  to  convert  a  stationary  or  spreading  ulcer  into  one  of 
the  healing  variety  by  amelioration  or  removal  of  the  cause  or  causes.  Thus 
syphilis  and  scurvy  demand  specific  treatment,  tuberculosis  general  tonic 
treatment.  Infective  ulcers,  in  general,  require  removal  of  the  infective  agent 
by  antiseptic  dressings,  the  application  of  strong  antiseptics,  the  cautery 


TREATMENT  OF  ULCERS  51 

or  wide  excision,  according  to  the  rate  of  spread.  Callous  ulcers,  where 
fibrous  tissue  is  in  excess,  may  be  scraped  to  remove  such  excess,  and  replace 
it  with  healthy  granulation  tissue,  or  even  may  be  excised.  The  blood- 
supply  may  be  improved  by  raising  the  affected  part  or  employing  supporting 
bandages  when  venous  obstruction  is  present,  as  in  ulcers  connected  with 
varicose  veins. 

Where  due  to  defective  innervation,  suturing  the  divided  nerves  is 
indicated.  Finally,  the  part  should  be  kept  at  rest,  as  by  slinging  the  arm, 
placing  the  leg  on  an  inclined  plane  or  on  a  splint,  or  by  performing  gastro- 
enterostomy for  gastric  or  duodenal  ulcer.  Where,  by  such  devices,  the 
ulcer  has  been  made  to  assume  the  healing  stage,  i.e.  has  been  converted 
into  a  healthily  granulating  wound,  treatment  consists  in  keeping  the  part 
aseptic  and  free  from  irritation.  Various  methods  are  used,  and  are  to  be 
altered  as  the  ulcer  shows  a  tendency  towards  such  conditions  as  hypertrophy 
of  its  granulations,  atrophy  of  granulations,  failure  of  the  epithelium  to 
grow  over  the  latter,  or  excessive  formation  of  fibrous  tissue,  i.e.  tendency 
to  become  callous. 

Aseptic  lint  or  gauze  spread  with  boric  ointment,  to  which  oil  of  euca- 
lyptus has  been  added  in  the  quantity  of  10  m.  to  the  ounce,  is  a  useful 
application,  especially  for  large  ulcers  following  burns.  Sterile  oil-silk 
protective,  wrung  out  of  saline  solution,  may  be  used  ;  such  applications 
are  changed  daily.  Where  the  granulations  are  becoming  too  large  they 
should  be  reduced  by  application  of  solid  silver  nitrate  or  pure  carbolic 
at  intervals  of  a  few  days,  or  scraped  away  with  a  sharp  spoon,  the  dressing 
being  as  before.  Where  progress  is  slow  stimulating  applications  are  useful, 
such  as  the  well-known  red  lotion,  which  consists  of  zinc  sulphate  2  to  5  gr. 
tincture  of  lavender  15  m.  to  the  ounce  of  water ;  this  is  applied  on  sterile 
lint,  and  kept  moist  by  covering  with  oil-silk  protective.  Where  the  growth 
of  epithelium  is  slow  it  may  be  increased  by  the  application  of  ointment 
of  5  to  10  per  cent.  Scarlet  R.  in  vaseline.  This  is  used  alternately  with 
boric  ointment,  as  it  may  prove  rather  irritating. 

Each  ulcer  must  be  treated  on  its  merits,  altering  the  applications  from 
soothing  to  stimulating,  as  seems  indicated  by  its  appearance,  and  not 
employing  a  fixed  routine  for  all  cases. 

Finally,  where  the  raw  surface  is  extensive,  as  after  burns,  there  will, 
as  has  been  already  mentioned,  be  reached  a  point  where  the  epithelium 
refuses  to  grow  further  over  the  granulations,  or  if  it  should  do  so  the  result- 
ing scar  is  weak  and  degenerates  into  an  ulcer  on  the  least  provocation  : 
the  reason  being  that  the  blood-supply  of  the  central  part  of  the  cicatrix 
is  impaired  by  the  contraction  of  the  scar  tissue. 

In  such  cases  skin-grafting  will  be  advisable,  and  this  will  be  more 

CO  7 

successful  if  performed  fairly  early  before  much  cicatrization  has  taken 
place.  Thus  in  widespread  burns,  where  we  may  be  fairly  certain  that 
healing  will  take  very  long,  and  much  contraction  must  take  place,  skin- 
grafting  should  be  done  as  soon  as  the  surface  is  clean,  that  is  in  two  to 
four  weeks  in  most  cases,  after  we  are  sure  that  there  are  no  islands  of 


52 


A  TEXTBOOK  OF  SURGERY 


epithelium  Left,  scattered  over  the  granulating  Burface,  which  mighl    by 
proliferation  cover  in  the  gap. 

There  are  three  plans  of  covering  in  such  defects  :  (1)  by  pedunculated 
flaps  :  (2)  by  free  grafts  of  the  whole  thickness  of  the  skin  ;  (:3)  by  grafts 
of  only  pari  of  the  thickness  of  the  skin  as  devised  by  Thiersch. 

(1)  In  this  method  a  suitable  flap  is  dissected  up  from  a  neighbouring 
sulfate,  taking  for  choice  a  part  well  supplied  with  vessels,  and  turning  it 
round  till  it  can  be  sutured  into  the  defect.  Much  ingenuity  has  been 
displayed  in  devising  such  operations.     The  skin  of  the  face  and  neck  is 

especially  favourable  for  form- 
ing such  flaps,  since  owing  to 
the  profuse  blood-supply  the 
pedicle  of  attachment  can  be 
made  very  narrow  and  the  flap 
readily  turned  in  the  needful 
direction.  Such  operations  are 
described  under  the  general  term 
"  plastic  operations,"  which  also 
includes  such  operations  as  those 
for  hare-lip,  cleft-palate,  hypo- 
spadias, &c. 

(2)  The  use  of  free  grafts  of 
the  whole  thickness  of  the  skin 
is  advisable  where  the  area  to 
be  covered  is  small  and  a  good, 
tough  covering  is  needed,  as, 
e.g.  to  take  the  place  of  a  finger- 
tip which  has  been  lost  in  any 
manner.  This  method,  devised 
by  Woolf ,  is  to  remove  a  portion 
of  skin  from  some  place  where 
loose  skin  is  abundant,  such  as 
the  abdomen,  of  suitable  size 
and  shape.  (Owing  to  the 
elastic  contraction  such  a  graft  should  be  cut  one-third  greater,  in  each 
diameter,  than  the  gap  to  be  filled.)  The  fat  is  removed  from  the  under- 
surface  of  the  graft,  and  it  is  applied  to  the  ulcerated  surface  which  has 
previously  been  curetted  to  remove  excess  of  granulations,  and  sutured  in 
situ ;   if  successful,  such  grafts  will  be  tolerably  firm  in  a  week. 

(3)  Skin-grafting  by  Thiersch's  Method.  The  principle  involved 
is  to  remove  the  epidermis  with  the  Malpighian,  or  growing  layer,  over  a 
large  area,  and  the  line  of  section  should  pass  through  the  skin  at  such  a 
level  that  the  papillse  of  the  dermis  are  cut  through  about  half-way  up. 
By  so  doing  the  tops  of  the  papillae  and  the  Malpighian  layer  of  epidermis 
over  them  are  in  the  detached  graft  and  form  a  multitude  of  islands  of 
rapidly  growing  epithelium,  connected  together  by  the  epidermis,  which 


Fig.  13.     Results  of  Bkin-grafting   by  Thin 
method:    after  excision  of  large  epitheliomatous 
ulcer  and  treatment  with  radium. 


SKIN-GRAFTING  53 

by  their  proliferation  speedily  clothe  the  surface  of  the  ulcer  with  epithelium  ; 
while  there  are  left  on  the  surface  from  which  the  graft  is  cut  the  depressions 
between  the  papilla?,  filled  with  epithelium,  which  soon  regenerate  and 
cover  over  the  denuded  surface.  Thus  very  large  areas  can  be  denuded 
for  grafting,  since  the  robbed  surface  is  covered  again  with  epithelium  in 
a  few  days,  and  there  is  no  loss  of  true  skin  and  practically  no  scarring. 

TECHNIQUE   OF   SKIN-GRAFTING 

The  graft  may  be  removed  from  any  part,  where  the  skin  is  fine  and 
pliable  ;  the  place  of  election  is  the  inner  and  front  surface  of  the  left  thigh, 
since  here  large  grafts  can  be  obtained,  and  the  surgeon  cuts  towards  the 
feet  in  a  fore- handed  manner,  but  the  other  thigh,  arm,  or  abdomen  may 
also  be  used.  The  skin  is  prepared  by  shaving,  if  necessary,  and  washing 
with  ether,  followed  by  biniodide  and  spirit,  the  latter  washed  off  with 
normal  salt  solution.  This  is  done  a  few  hours  before  operation,  and  the 
part  covered  with  sterile  gauze.  To  cut  the  graft  the  skin  is  rendered  taut 
by  placing  a  spatula  upon  it,  and  pulling  the  skin  with  this  in  the  opposite 
direction  to  the  line  of  the  section.  As  large  a  level  surface  as  possible  is 
obtained  by  supporting  the  flaccid  muscles  from  below.  The  skin  and 
grafting  razor  (which  must  be  sharp)  are  lubricated  with  a  mixture  of  equal 
parts  of  glycerine  and  spirit,  and  after  adjusting  the  razor  flat,  the  graft 
is  cut  by  a  series  of  rapid  sawing  movements,  the  quicker  the  better.  With 
practice  grafts  several  inches  long  and  two  or  more  inches  wide  can  be  cut ; 
to  be  successful  a  delicate  hand  is  needed.  If  the  cut  should  go  too  deep, 
so  that  more  than  the  tops  of  the  papillae  are  cut  off,  and  the  fat  exposed, 
it  is  best  to  stop  and  try  again  in  another  place.  The  surface  denuded  will 
be  covered  with  pin-head  bleeding-points,  sections  of  the  papillae.  The 
graft  is  next  placed  in  warm  normal  salt  solution,  and  the  process  repeated 
till  enough  grafts  have  been  obtained.  If  many  are  to  be  cut  several  razors 
should  be  to  hand,  since  the  cutting  of  grafts  soon  blunts  steel,  and  a  blunt 
razor  is  useless  for  the  purpose.  The  grafts  are  next  recovered  from  the  salt 
solution  with  broad  spatulae,  and  spread  carefully  (right  side  up)  on  the 
granulating  surface,  which  may  be  previously  scrubbed  with  gauze,  or  from 
which  the  granulations  may  have  been  removed  with  a  sharp  spoon,  in  old- 
standing  cases.  This  process  of  freshening  up  the  surface  to  be  grafted 
is  done  before  the  grafts  are  cut,  and  all  bleeding  stopped  by  pressure  before 
the  grafts  are  applied.  The  grafts  having  been  spread  over  the  surface, 
slightly  overlapping,  and  all  air  bubbles  squeezed  out  by  manipulation  with 
long  needles  ;  strips  of  perforated  sterile  silk-protective  are  placed  over  the 
grafts,  a  layer  of  gauze  placed  over  this,  and  the  whole  carefully  fixed  with 
strapping.  This  last  is  important,  for  if  merely  bandaged  the  whole  is  likely 
to  slip,  and  the  surgeon  has  the  mortification  later  of  finding  the  grafts, 
which  should  have  covered  say,  the  breast,  in  the  middle  of  the  back.  When 
hollow  cavities  are  to  be  grafted,  as  after  the  radical  mastoid  operation, 
the  graft,  which  must  be  full  large,  is  placed  over  the  mouth  of  the  cavity, 
pegged  at  the  corners  with  needles,  and  the  slack  central  part  forced  firmly 


:,l  A  TEXTBOOK  OF  SURGERY 

into  the  cavity  with  gauze  packing  till  adjusted  to  the  walls.  Grafts  should 
not  be  dressed  for  five  to  BeveD  days,  even  if  foul  smelling.  After  removal 
of  the  gauze  the  protective  is  floated  off  with  salt  solution,  and  fresh  sterile 
protective  reapplied.  The  dressing  is  changed  in  three  to  four  days,  when 
boric  ointment  on  gauze  may  be  employed  till  the  new  epidermis  is  Btrong. 
The  area  denuded  soon  heals  under  a  dressing  of  sterile  gauze.  Reverdin's 
plan  of  sowing  small  fragments  broadcast  over  a  raw  surface  is  obsolete. 

Excision  of  ulcers  is  the  best  line  of  treatment  in  many  cases,  either 
followed  by  grafting,  as  described  in  the  last  section,  or  by  suturing,  where 
the  neighbouring  tissues  can  be  readily  brought  together,  as  in  the  stomach 
and  intestine,  or  where  the  ulcer  is  malignant,  whether  this  is  possible  or  not 
as  in  the  tongue,  breast,  &c. 

CHARACTERS   OF   SPECIAL   FORMS   OF   ULCER   AND   POINTS   IN 
THEIR   TREATMENT 

In  the  preceding  section  mention  has  been  made  of  various  forms  of 
ulcers,  some  of  which  are  so  common  that  a  more  detailed  consideration 
will  be  needed,  since  correct  diagnosis  of  their  cause  is  often  essential  to 
successful  treatment. 

Traumatic  Ulcers.  Such  ulcers  as  arise  from  crushes  and  burns,  &c, 
need  little  description.  They  are  due  to  sloughing  of  the  surface  tissues, 
and  this  is  evident  from  the  grey  or  black  colour  and  insensitive  condition 
of  the  part :  after  separation  of  the  sloughs  they  assume  the  appearance 
of  healing  ulcers  or  granulating  wounds,  unless  contamination  with  micro- 
organisms has  occurred  and  spreading  infection  is  taking  place,  when  such 
ulcers  may  be  inflamed,  spreading,  phagedenic,  sloughing,  &c. 

The  treatment  of  such  conditions  consists  in  rendering  the  injured  part 
aseptic  from  the  outset,  e.g.  by  painting  with  iodine  solution  (crushes)  or 
picric  acid  (burns),  and  enveloping  with  sterile  dressings,  or  other  methods, 
which  will  be  described  for  special  lesions.  The  later  treatment  is  as  for 
simple  healing  ulcer,  chronic  ulcer,  or  complicated  spreading  ulceration. 

Ulcers  arising  from  Pressure.  Pressure,  Bed  or  Decubitus 
Ulcers.  These  are  important,  since  their  occurrence  is  often  a  source  of 
reproach  to  the  surgeon  or  the  nurse.  Their  common  situation  is  over  bony 
prominences  where  there  is  pressure,  e.g.  the  malleoli  of  the  ankle,  the 
condyles  of  the  humerus,  the  head  of  the  fibula  from  splints  ;  over  the  sacrum 
or  posterior  surface  of  the  os  calcis,  from  pressure  of  these  against  the  bed, 
due  to  the  patient's  wreight  (bed  or  decubitus  sores).  In  some  cases  there 
is  in  addition  a  nervous  element  in  the  production  of  bed-sores,  since  they 
occur  most  easily  and  increase  in  size  most  rapidly  in  paraplegic  patients 
(thus  being,  in  part,  ulcers  from  deficient  innervation).  "  Ingrowing  toe- 
nail "'  is  a  common  form  of  pressure  ulceration. 

Prevention  of  such  sores  is  possible  in  most  cases.  Thus  splints  must 
be  adequately  padded,  particularly  over  bony  prominences,  eg.  where  the 
leg  has  to  be  placed  on  back  splint  a  heel-pad  is  placed  not  under  the  os  calcis 
or  prominence  of  the  heel,  but  behind  the  tendo-Achillis,  just  above  the 


SPECIAL  ULCERS  55 

heel,  taking  the  pressure  off  the  latter  bony  prominence.  Bed-sores  are 
prevented  by  avoiding  creases  and  lumps  in  the  bedding,  using  water 
pillows  under  the  sacrum  or  occiput,  changing  the  sheets  if  soiled  with  urine, 
fasces,  or  other  discharges,  to  prevent  the  skin  becoming  sodden  with  these 
in  situations  where  there  is  pressure.  Another  practical  point  is  to  avoid 
antiseptics  or  anaesthetics  running  under  the  patient  at  an  operation,  or 
much  irritation  and  even  ulceration  may  result  if  the  patient's  back  is  soaked 
in  chloroform  or  biniodide  and  spirit  for  an  hour  or  more. 

In  bedridden  patients  great  care  must  be  taken  of  the  skin  over  the 
back.  It  should  be  washed  gently  with  soap  and  water,  gently  dried,  and 
rubbed  with  methylated  spirit,  finally  pow'ered  with  a  dusting  powder  of 
boracic  acid  and  starch.  Turning  the  patient  at  regular  intervals,  when 
possible,  to  distribute  the  pressure  on  to  different  points,  or  where  this  is 
not  feasible,  slight  alterations  of  mattress  and  pillows  will  often  assist  in 
promoting  better  circulation  (since  these  ulcers  are  instances  of  ansemic 
necrosis,  the  anaemia  being  due  to  pressure). 

Extra  care  is  needed  where  redness  is  present,  and  it  is  clear  that  local 
necrosis  may  follow.  Where  necrosis  has  taken  place  and  an  ulcer  is  actually 
present  this  must  be  kept  clean  by  non-irritating  antiseptic  dressings  to 
prevent  the  spread  of  infection.  Ring  pads  around  the  ulcer  are  useful  in 
relieving  pressure  on  its  surface.  In  the  early  stage  of  excoriation  zinc- 
oxide  ointment,  or  gauze  soaked  in  a  mixture  of  castor-oil  and  balsam  of 
Peru  or  Friar's  balsam  (Tinct.  Benzoini  Co.),  is  antiseptic  and  soothing ;  later 
boracic  fomentations,  stimulating  lotions,  as  zinc  sulphate,  skin-grafting,  &c, 
will  be  indicated. 

In  the  acute  stage  the  dressing  should  be  changed  every  two  hours,  and 
if  pressure  can  be  entirely  removed  by  placing  the  patient  in  some  other 
position,  such  as  on  the  side  where  the  ulcer  is  over  the  sacrum,  much  good 
will  be  achieved. 

Ulcers  op  Nervous  Origin.  Trophic  Ulcers.  These  are  exemplified 
by  cases  of  section  of  the  median  or  ulnar  nerves,  or  syringomyelia.  Here 
minor  injuries,  such  as  excessive  heat,  cold,  abrasions,  &c,  are  not  felt, 
and  infection  occurs,  painlessly  leading  to  ulceration,  painless  whitlows, 
loss  of  phalanges,  &c. 

An  allied  condition  is  found  in  the  sole  of  the  foot  in  tabes,  known  as 
"  perforating  ulcer."  This  ulcer  results  from  inflammation  and  suppuration 
in  a  corn  which,  in  the  absence  of  sensation,  is  allowed  to  progress,  till  the 
resulting  ulcer  penetrates  deeply  into  the  tissues  of  the  foot  and  finally 
penetrates  the  bones  and  joints  of  the  metatarsus.  Perforating  ulcers  are 
usually  found  under  one  of  the  metatarsal  heads  ;  the  process  is  of  a  chronic 
character,  so  that  the  ulcer  presents  itself  as  a  cavity  surrounded  with 
and  lined  in  the  superficial  part  by  horny  epithelium,  extending  as  a  sinus 
lined  by  granulation  tissue  into  the  depths  of  the  sole,  and  ending  in  carious 
and  necrotic  foci  in  the  bones  and  joints.  In  cases  of  injuries  and  diseases 
of  the  spinal  cord  (myelitis)  bed-sores  may  rapidly  develop  in  spite  of  every 
care,  the  skin  becoming  red  and  (Edematous,  shortly  turning  black,  and 


56  A  TEXTBOOK  OF  SURGERY 

breaking  down  with  rapid  formation  of  sloughs  and  large  ulcers.  Such  acute 
bed-sores  are  very  likely  to  lead  to  fatal  general  infection.  The  treat  incut 
of  such  cases  consists  in  repairing  the  nerve  Lesion,  \\  here  possible,  by  sutur- 
ing the  divided  nerves.  The  surface  should  be  protected  from  injury  and 
kepi  under  aseptic  dressings.  In  the  case  of  perforating  ulcers  removing 
the  horny  epithelium  with  knife  or  salicylic  collodion  (60  gr.  salicylic  acid 
to  the  ounce  of  collodion),  and  resting  the  part  by  confining  the  patient  to 
bed,  will  cure  in  the  earlier  stages.  Where  the  bones  are  involved  partial 
amputation  or  excision  of  the  affected  metatarsal  bone  may  be  needed. 
For  acute  bed-sores  the  treatment  is  as  for  other  decubitus  ulcers,  but  such 
acute  manifestations  are  in  general  the  beginning  of  the  fatal  exitus. 

Ulcers  associated  with  Varicose  Veins.  The  form  commonly  met 
with  present  themselves  as  callous  ulcers  with  sharply  punched-out  edges, 
dry,  glazed  floors,  devoid  of  granulations,  often  with  infiltrated  base  and 
periostitis  of  the  underlying  tibia,  which  may  extend  widely  up  and  down 
the  bone  ;   such  ulcers  are  slowly  progressive  and  may  encircle  the  leg. 

In  other  instances  the  type  is  rather  that  of  the  weak  ulcer,  with  small 
ill-developed  granulations,  thin,  dirty  discharge  when  near  the  ankle.  Such 
ulcers  may  be  "  irritable."  The  discharge  of  such  ulcers  leads  to  eczema 
and  pigmentation  of  the  surrounding  skin,  for  which  reason  they  are  often 
known  as  "  eczematous  ulcers."  Varicose  ulcers  are  usually  single,  often 
large,  and  occur  in  the  lower  third  of  the  leg  in  a  patient  with  marked 
varicose  veins. 

The  Treatment  of  Varicose  Ulcers.  This  consists  of  relieving  the 
venous  congestion  by  elevating  the  limb  on  an  inclined  plane  (the  patient 
being  in  bed),  and  removing  the  varicose  veins  if  they  are  of  the  operable 
type  (see  Varicose  Veins,  in  the  section  on  Diseases  of  Veins).  The  ulcer 
is  cleaned  with  pure  carbolic,  fomentations,  &c,  in  the  inflamed  stage ; 
stimulating  lotion  or  Scarlet  ointment,  alternating  with  boric  ointment, 
are  employed  later.  Where  the  ulcer  is  very  large  the  surface  is  curetted, 
or  the  ulc?r  excised,  and  the  raw  surface  covered  with  Thiersch  skin-grafts. 
which  greatly  accelerates  healing  and  is  often  the  best  method  of  treatment. 
Where  the  patient  cannot  lie  up,  the  venous  return  is  assisted  by  bandages 
or  strapping  after  the  ulcer  has  been  rendered  tolerably  aseptic  by  applica- 
tion of  silver  nitrate,  or  pure  carbolic,  followed  by  fomentations.  Unna's 
method  is  useful  in  such  cases.  The  ulcer  must  be  first  rendered  clean  and 
in  the  healing  stage.  Such  a  limb  is  covered  from  ankle  to  knee  with 
sterile  gauze  bandage  steeped  in  a  mixture  of  gelatine  5,  zinc  oxide  5, 
glycerine  8,  boric  acid  1,  water  (i.  This  mixture  is  applied  warm,  when  it 
is  liquid,  and  solidifies  on  cooling.  Over  a  bandage  soaked  in  this  paste  a 
dry  bandage  is  applied  ;  on  setting  the  limb  is  enveloped  from  ankle  to 
knee  in  a  firm,  elastic,  aseptic,  non-irritating  case,  which  supports  the  veins 
and  forms  a  good  dressing  for  the  ulcer.  This  paste  dressing  may  be  left 
in  position  a  week  or  more  ;  the  patient  is  directed  to  keep  the  limb  raised 
whenever  possible.  Such  treatment  will  sometimes  end  in  cure,  but  mo:e 
often  will  only  prevent  further  spread  of  the  ulcer.     Recumbent  treatment 


SPECIAL  ULCERS  57 

is  far  more  satisfactory.  Where  the  nicer  is  very  extensive,  surrounding 
the  limb,  adherent  to  the  bone,  associated  with  matting  of  tendons,  great 
pain,  and  disability,  amputation  is  the  best  resource,  especially  if  spreading 
infection  is  present. 

Syphilitic  Ulcers.  These  occur  in  all  stages  of  the  disease  and  in 
most  parts  of  the  body.  We  need  refer  here  only  to  those  of  the  leg.  which 
may  resemble  those  associated  with  varicose  veins.  The  syphilitic  ulcers, 
however,  usually  occur  in  the  upper  part  of  the  leg.  around  the  knee,  and 
are  often  multiple,  seldom  larger  than  a  two-shilling  piece.  Well  healed 
"  tissue  paper  "  scars  of  similar  ulcers,  now  healed,  are  often  present  as 
well.  The  ulcers  themselves  are  round,  punched  out  with  sharply  cut 
edges  ;  the  floor  is  covered  at  first  with  the  usual  tough  yellow  "  wash- 
leather  ;'  slough,  and  they  commence  as  a  lump,  which  breaks  down,  and 
not  as  a  raw  surface  which  gradually  extends,  which  is  the  manner  of  originat- 
ing  in  varicose  ulcers.  Finally,  the  history  and  the  serum  reaction  will 
show  whether  the  patient  has  had  syphilis.  Of  course,  gummatous  ulcers 
may  occur  in  the  lower  third  of  the  leg.  or  a  patient  with  syphilis  may  suffer 
from  varicose  ulcers.  In  doubtful  cases  administration  of  mercury  and 
iodides  or  salvarsan  is  advisable,  since  if  syphilitic  the  ulcer  will  rapidly 
heal  on  such  appropriate  treatment. 

Scorbutic  Ulcers  (Scurvy).  These  appear  as  ulcers,  arising  from 
slight  local  lesions,  bruises,  scratches,  &c,  and  are  characterized  by  their 
hypertrophic  granulations,  inflamed  cedematous  margins,  and  thin,  foul, 
sloughy  discharge.  The  cause  is  likely  to  be  missed  unless  inquiry  be  made 
into  the  dietary  of  the  patient,  when  deficient  feeding  and  absence  of  fresh 
food  will  be  noted.  Antiseptic  dressings  and  a  generous  diet  of  fresh  meat 
and  vegetables,  lime  juice,  &c,  will  rapidly  cure  if  the  patient's  condition 
is  not  too  depressed  to  respond. 

Gouty  Ulcers.  These  occur  on  the  knuckles  from  the  deposit  of  urate 
of  soda  (chalk  stones),  such  deposits  acting  as  foreign  bodies  and  ulcerating 
through  the  skin.  The  condition  resembles  suppurative  ulceration  at  first 
sight,  but  there  is  less  constitutional  disturbance,  and  the  yellowish-white 
material  coming  from  the  ulcers  is  found  not  to  be  pus  but  urates  (detected 
by  the  murexide  test)  ;  also  there  will  be  other  signs  of  gout,  as  tophi  in 
the  ears,  arterio-sclerosis,  and  urine  of  high  specific  gravity  containing 
urates  or  uric  acid  in  abundance. 

Treatment.  The  redundant  masses  of  urates  should  be  removed  from 
the  ulcers  with  a  sharp  spoon,  and  aseptic  dressings  applied  ;  while  internal 
remedies  for  gout  are  indicated,  viz.  colchicum,  alkalis  and  free  purgation. 

Tuberculous  Ulcers  when  on  the  surface  of  the  body  are  characterized 
by  their  undermined  edge  surrounded  by  purple,  shiny,  weak,  unhealthy- 
looking  skin,  and  large,  flabby,  anaemic  granulations.  In  the  internal 
organs  or  on  mucous  membranes  they  may  at  times  assume  a  more  robust 
type,  being  fibrous,  and  to  some  degree  indurated,  not  unlike  squamous 
celled  carcinoma  ;  such  tuberculous  ulcers  are  to  be  seen  on  the  tip  of  the 
tongue  and  the  tonsil. 


A  TEXTBOOK  OF  SURGERY 

'mcnt.  The  general  treatment  of  tuberculosis  is  described  in  a 
later  section  ;  locally  the  ulcer  should  be  excised  or  curetted  and  allowed 
to  heal  by  granulation  or  grafted  by  Thiersch's  method.  Often  superficial 
ulceration  is  only  a  sequel  of  deep-seated  tuberculosis,  e.g.  of  glands,  and 
these  will  need  removal  by  excision  or  free  curetting  if  the  ulcer  is  to  heal. 

There  are  many  other  forms  of  ulcer,  the  appearance  and  treatment 
of  which  will  be  dealt  with  under  special  tissues  and  organs  as  gastric, 
duodenal,  typhoid,  dental  ulcers,  &c. 

GANGRENE 

The  terms  gangrene,  sloughing,  mortification,  are  applied  to  death  or 
necrosis  of  considerable  portions  of  tissue,  as  opposed  to  ulceration  or 
molecular  death. 

Further,  it  must  be  added  that  in  gangrene  death  is  associated  with 
putrefaction  of  the  dead  tissues  or  drying  and  mummification  of  these, 
since  necrosis  occurring  without  such  accompaniments  is  not  described  as 
gangrene,  e.g.  anaemic  infarcts,  ischaemic  contracture  of  muscle,  and  focal 
necroses  generally.  The  term  Slough  is  applied  to  the  mass  of  dead  or 
necrosed  tissue ;  in  the  case  of  bone  such,  a  slough  is  called  a  Sequestrum. 
In  a  general  way  gangrene  is  divided  into  two  main  forms,  the  dry  and  the 
moist.  In  the  former  the  dead  tissue  dries  up  with  little  evidence  of  putrefac- 
tion, or,  in  other  words,  becomes  mummified.  In  the  latter  the  tissue 
juices,  blood,  and  lymph,  &c,  remain  in  the  tissues  in  quantities,  and 
putrefaction  is  almost  invariable  ;  the  reason  of  the  difference  is  that  bacteria 
require  moisture  to  develop,  and  putrefaction  in  dry  tissues  is  not  possible. 

Pathology,  (a)  Dry  Gangrene.  This  is  a  relatively  slow  process, 
mostly  due  to  slow  obliteration  of  the  arterial  supply  to  the  part,  as  in 
senile  arteritis.  The  tissues  affected  become  anaemic  and  dry ;  necrosis 
takes  place  with  the  usual  cell-degenerations.  The  part  thus  rendered 
anaemic  becomes  dark,  shrivelled,  and  finally  black,  resembling  in  appear- 
ance a  mummy.  Dry  gangrene  is  seldom  perfect  except  in  small  parts, 
e.g.  toes,  fingers,  ear-tips,  &c.  In  more  fleshy  parts  infection  with  putrefac- 
tive organisms  almost  always  takes  place,  and  decomposition  results  ;  the 
condition  then  closely  resembles  that  of  moist  gangrene. 

Finally,  separation  takes  place,  the  gangrenous  part  being  gradually 
cut  off  by  a  process  of  inflammation  at  its  upper  limit,  called  the  "  lino  of 
demarcation."  Across  this  line  of  demarcation  there  is  an  inflammatory 
reaction  with  hyperaemia,  exudation  of  cells,  and  erosion  of  the  tissues 
by  phagocytic  cells,  so  that  the  dead  tissues  are  cut  off  from  the  living  by 
a  layer  of  granulation  tissue  and  ultimately  drop  off.  This  process  of 
separation  may  take  months  to  be  accomplished,  since,  owing  to  the  small 
blood-supply  to  the  area  of  demarcation,  the  inflammatory  reaction  is 
sluggish. 

(6)  Moist  Gangrene.  Here  the  processes  are  more  rapid,  the  part 
becoming  swollen  and  passing  through  various  colour  changes  :  red,  purple, 
black,  green,  and  grey.     The  former  colours  representing  the  initial  stages, 


GANGRENE  59 

or  threatening  gangrene,  the  latter  pointing  to  gangrene  fully  developed. 
The  tissues  are  infiltrated  with  oedema  and  blood,  and  often  decompose 
rapidly,  sometimes  with  formation  of  gas  in  the  interior.  Blebs  and  vesicles 
on  the  skin  are  common.  This  type  of  gangrene  often  spreads  rapidly  up 
the  limb  (should  it  originate  in  an  extremity),  advancing  several  inches  in 
twenty-four-^purs.  There  is  little  tendency  to  form  a  line  of  demarcation, 
and  constitutional  depression  is  severe.  Such  severe  spreading  forms  of 
gangrene  are  always  due  to  infection  with  pathogenic  organisms,  but  in 
some  instances  moist  gangrene  may  be  due  simply  to  destruction  of  the 
blood-supply  as  by  ligature  of  the  main  artery  and  vein.  In  such  cases 
the  gangrenous  part  though  moist  may  remain  aseptic  (if  suitable  treatment 
be  adopted)  for  a  considerable  time,  and  not  spread  rapidly,  but  form  a 
line  of  demarcation.  Still,  such  cases  often  take  on  a  spreading  form  after 
a  while  from  entrance  of  some  infection  into  the  dead  tissues.  An  inter- 
mediate type  is  often  found  in  practice,  which  is  due  to  vascular  impair- 
ment, but  where  the  bulk  of  the  tissues  is  too  great  to  permit  of  drying  and 
mummification  readily  taking  place.  The  progress  is  slow,  areas  of  conges- 
tion becoming  dark  and  finally  black,  appear  (usually  on  the  foot),  while 
blebs  and  vesicles  are  noted  ;  there  is  some  tendency  to  form  a  line  of 
demarcation,  but  this  often  gives  way,  and  the  gangrene  spreads  higher 
up.  Such  cases  may  be  regarded  as  starting  aseptically  from  vascular 
deficiency,  but  becoming  later  infected  and  ending  as  moist  gangrene, 
the  slower  rate  of  spread  in  such  case  being  due  to  a  milder  variety  of 
infection. 

Clinical  Appeakances.  The  signs  will  be  those  of  actual  or  impending 
death  of  the  part  whether  from  deficient  blood- supply  or  infection,  together 
with  those  of  mummification  or  putrefaction. 

The  signs  of  actual  or  impending  death  of  a  part  are  :  Loss  of  pulse, 
heat,  sensation,  and  function,  and  changes  in  colour  and  consistency. 

(1)  Loss  of  pulse  may  result  from  injury  or  embolism  of  a  main  artery, 
and  in  itself  merely  suggests  that  gangrene  may  occur,  since  many  cases 
of  this  nature  recover  from  an  increase  in  the  collateral  circulation. 

(2)  Loss  of  heat  is  due  to  impaired  blood-supply.  Where  the  preceding 
changes  are  inflammatory  there  will  be  at  the  outset  increased  local  heat 
(as  is  often  the  case  at  the  commencement  of  moist  gangrene). 

(3)  Loss  of  sensation  is  often  preceded  by  extreme  pain,  as  the  nerves 
in  the  part  die,  and  comes  on  later  than  loss  of  pulse,  heat  and  pallor.  This 
may  be  taken  as  definite  proof  of  death  of  a  part,  all  forms  of  sensation  being 
affected. 

(4)  Loss  of  function  is  chiefly  noted  in  the  absence  of  movements,  as 
in  the  muscles  of  a  gangrenous  limb,  or  the  flaccid  condition  of  gangrenous 
intestine  in  a  strangulated  hernia. 

(5)  Colour  changes  are  partly  due  to  deficient  circulation,  partly  owing 
to  the  changes  of  drying  and  putrefaction.  In  some  cases  complete  pallor 
will  point  to  grave  deficiency  of  the  blood-supply  ;  in  other  cases,  however, 
the  part  may  not  be  bloodless,  but  the  reappearance  of  the  colour  after 


60  A  TEXTBOOK  OF  SURGERY 

compression  of  an  area  of  skin  will  he  much  slower  than  on  fche  sound  side 
Later,  when  circulation  is  completely  arrested,  there  will  he  no  alteration 
in  colour  on  compressing  the  part.  Reddish-purple  patches  on  the  skin. 
turning  to  brown  and  black,  are  found  in  slowly  advancing  gangrene,  and 
indicate  a  local  destruction  of  blood-vessels  and  extravasation  of  blood 
into  the  tissues.  The  same,  when  found  on  a  more  gross  scale  with  wide- 
spread swelling  of  the  tissues,  which  rapidly  turn  from  purple  to  black  and 
green,  indicate  a  rapidly  spreading  moist  gangrene.  The  hard,  dry, 
brownish-black  condition  known  as  mummification  requires  no  further 
description. 

Terminations  of  Gangrene,  (a)  The  gangrenous  part  may  be 
separated  by  a  process  of  local  ulceration  described  as  the  line  of  demarca- 
tion, and  be  cast  off.  the  raw  surface  left  healing  by  granulation.  As 
instances  of  this  we  may  mention  small  local  areas  of  gangrene  of  the 
extremities,  e.g.  toes  ;  gangrene  from  infection,  such  as  boils  and  carbuncles, 
and  often  after  superficial  injuries  as  burns,  crushes,  bed-sores,  &c. 

(b)  The  process  may  spread  till  the  patient  is  killed  by  the  poison 
absorbed  from  the  gangrenous  mass ,  or  some  large  vessel  is  eroded,  and  fatal 
haemorrhage  takes  place. 

General  Treatment  of  Gangrene,  (a)  Prophylaxis.  This  includes 
care  in  the  application  of  splints  and  bandages,  care  of  the  back  in  bed- 
ridden patients,  as  described  under  bed-sores  ;  attention  to  the  circulation 
in  the  feet  of  the  aged,  well-fitting  footgear,  warmth,  massage,  avoiding 
injury  in  cutting  corns,  &c,  finally  improving  the  circulation  by  arterio- 
venous anastomosis  in  suitable  cases,  where  gangrene  threatens. 

(b)  In  removing  the  gangrenous  mass  at  a  suitable  distance  above  the 
area  destroyed  in  cases  where  separation  by  natural  means  is  likely  to  be 
unsuccessful  or  where  it  will  take  a  very  long  time,  as  when  a  considerable 
mass  of  tissue  is  destroyed. 

(c)  Combating  the  action  of  infective  organisms  by  local  antiseptic 
measures  and  general  treatment,  such  as  maintaining  the  strength  by 
generous  diet  and  stimulants  and  possibly  by  the  use  of  serum  or  vaccine 
therapy. 

Special  Forms  of  Gangrene.  In  all  kinds  of  gangrene  a  large  part  of 
the  condition  is  due  to  defects  in  the  blood-supply  of  the  part  affected,  but 
injuries  also  play  an  important  part  as  antecedents  of  such  vascular 
deficiency,  and  infections  may  be  either  antecedents  or  consequences  of 
such  deficiency. 

As  the  type  of  gangrene  depends  a  good  deal  on  the  cause,  we  may 
divide  the  condition  into  the  following  types  on  a  basis  of  causation  : 

A.  Traumatic  Gangrene. 

B.  Non-traumatic  Gangrene  of  Vascular  Origin. 

C.  Infective  or  Microbic  Gangrene. 

A.  Traumatic  gangrene  maybe  divided  into:  (1)  Direct;  where  the 
effect  is  largely  due  to  immediate  destruction  of  tissues,  though  injury 
of  small   blood  vessels   often  plays  an  important  part   in   the   causation. 


TRAUMATIC  GANGRENE  61 

(2)    Indirect  traumatic   gangrene  or  traumatic  gangrene  due  to  vascular 
deficiency. 

(1)  Direct  traumatic  gangrene.  This  may  be  due  to  crushes,  burns, 
scalds,  corrosive  chemicals,  frost-bite,  the  pressure  of  splints  and  bandages, 
or  decubitus  (bed-sores).  In  the  foetus  the  pressure  of  amniotic  bands  or 
the  umbilical  cord  may  cause  necrosis  and  amputation  of  an  extremity, 
but  being  under  aseptic  conditions  in  utero,  putrefaction  does  not  occur,  so 
perhaps  these  cases  can  hardly  be  classed  with  gangrene. 

Direct  traumatic  gangrene  is  often  of  a  minor  nature,  and  is  described 
under  various  injuries,  as  burns,  crushes,  &c,  also  under  ulcers,  as  splint - 
sores  and  bed-sores.  In  more  gross  injuries  the  gangrenous  condition  is  chiefly 
due  to  injuries  of  the  blood-vessels,  and  is  dealt  with  in  the  next  section. 
The  treatment  of  minor  varieties  of  gangrene  is  described  under  wounds, 
burns,  ulcers,  &c. 

Infection  of  such  minor  varieties  of  gangrene  may  occur  when  the 
condition  becomes  practically  that  of  infective  gangrene  and  is  described 
in  a  later  section. 

(2)  Indirect  (vascular)  traumatic  gangrene,  i.e.  from  injuries  to  blood- 
vessels. This  seldom  results  from  obliteration  of  an  artery  alone  (as  from 
bruising  and  consecutive  thrombosis,  rupture,  &c),  but  may  result  from 
such  injuries  in  patients  where  the  circulation  is  already  defective.  Obstruc- 
tion of  the  main  artery  and  vein  together  is  very  likely  to  lead  to  gangrene, 
especially  in  situations  where  the  anastomotic  circulation  is  not  first  class, 
e.g.  the  common  femoral  or  popliteal  arteries.  Gangrene  is  much  less  likely 
to  take  place  after  blocking  of  the  axillary  or  superficial  femoral  artery. 
Gangrene  of  the  intestine,  in  strangulated  hernias,  is  of  this  nature,  as  are 
cases  where  a  limb  has  been  too  tightly  bandaged. 

Treatment.  In  the  first  place  the  importance  of  prevention  must  be 
insisted  on  where  possible,  viz.  by  avoiding  over-zeal  in  applying  splints 
and  bandages.  Where  the  vessels  have  been  actually  injured  the  treatment 
is  as  follows.  Since  the  improvements  in  the  operative  technique  of  vas- 
cular surgery  these  cases  should  never  be  left  to  chance,  but  where  skilled 
attention  is  obtainable  the  site  of  injury  should  be  explored.  Some  attempt 
should  be  made  to  remove  the  obstruction  and  restore  the  lumen  of  the 
vessel  by  suture,  or  grafting  a  portion  of  vein  where  too  much  is  destroyed 
to  admit  of  immediate  suture  ;  since  if  the  circulation  can  be  maintained 
only  for  a  few  days,  the  increase  in  the  collateral  circulation  which  is  going 
on  all  the  time  will  give  the  part  a  good  chance  of  recovery  (see  Surgery  of 
the  Vascular  System).  Expectant  treatment  is  only  reasonable  where  the 
arterial  lumen  cannot  be  restored  or  where  skilled  assistance  is  not  to  be 
had.  Where  arterial  suture  is  not  feasible,  the  following  points  are  worth 
remembering.  Gangrene  from  arterial  and  venous  blocking  is  usually  of 
the  moist  variety  ;  hence  the  greatest  care  is  needed  to  prevent  infection 
of  the  dead  tissues.  In  such  cases  the  limb  should  be  rendered  aseptic  by 
painting  with  a  solution  of  2  per  cent,  iodine  in  spirit  and  covered  with  aseptic 
gauze,  kept  warm  with  not  over-hot  bottles  (lest  the  ill-nourished  tissues 


A  TEXTBOOK  OF  SURGERY 

be  binned),  and  kepi  in  a  raised  position  to  allow  of  every  chance  for  the 
increase  of  collateral  circulation.  Where  tin-  vein  is  intact  the  prognosis 
is  good;  where  this  is  also  occluded  the  chances  of  gangrene  supervening 
are  much  increased.  If.  however,  the  limb  be  maintained  in  a  state  of 
asepsis,  there  will  be  time  for  noting  the  formation  of  a  line  of  demarcation, 
when  amputation  close  above  this  should  be  performed.  Should  infection 
occur,  as  shown  by  level',  rigors,  constitutional  depression,  and  rapid  spread 
of  the  gangrenous  area  upwards,  it  will  be  necessary  to  amputate  considerably 
higher  than  the  obviously  gangrenous  tissues  if  spread  is  to  be  stayed  ; 
and  there  must  be  no  waste  of  time  in  waiting  for  a  line  of  demarcation  to 
form. 

In  certain  situations  immediate  resection  of  the  gangrenous  part  is 
indicated,  as  in  the  case  of  a  loop  of  gangrenous  intestine  (see  Abdomen). 

B.  Non-traumatic  Gangrene  from  Vascular  Changes.  Blocking 
of  arteries,  leading  to  gangrene,  may  be  due  to  (1)  organic  changes  in  the 
vessel  wall  (arteritis,  degenerations,  &c),  (2)  spasm  of  the  vessel  wall, 
(3)  embolism. 

(1)  Gangrene  arising  from  arterial  inflammations  and  degenerations  may 
be  divided  into  :  (a)  senile  or  endarteritic  ;  (b)  post-febrile  ;  (c)  diabetic. 

(a)  Senile  or  Endarteritic  Gangrene.  This  is  most  commonly  met 
with  in  old  persons,  resulting  from  the  diminution  in  arterial  calibre  due 
to  calcification,  but  very  similar  conditions  are  found  in  the  middle-aged 
and  even  the  young,  consequent  on  obliterative  arteritis,  whether  syphilitic 
or  of  unknown  cause.  The  gangrene  is  slowly  progressive  and  of  the  dry 
type.  The  onset  is  gradual.  There  are  neuralgic  pains  in  the  feet,  which 
are  cold  and  show  evidence  of  poor  circulation  (loss  of  the  pulses,  pallor, 
and  feeble  return  of  blood  to  the  part  after  expressing  with  the  finger). 
The  changes  are  bilateral  but  more  advanced  in  one  foot  than  the  other. 
After  a  while  definite  patches  of  gangrene  appear,  often  immediately  due 
to  slight  injuries,  as  tight  boots,  cutting  corns,  bruises,  crushes.  The  initial 
appearance  is  of  dusky  patches,  which  become  black  and  dry,  gradually 
destroying  some  portion,  usually  a  toe.  The  termination  varies  ;  the 
gangrenous  patch  may  remain  localised,  the  little  slough  separating,  or 
dusky  patches  may  appear  higher  up  on  the  foot,  coalescing  till  a  considerable 
part  of  the  foot  is  in  a  condition  of  dry  gangrene.  Lines  of  demarcation 
appear  and  some  separation  takes  place,  but  often  the  process  starts  again 
above  the  line  of  demarcation,  and  thus  the  gangrene  slowly  spreads  up 
the  leg.  Later  putrefactive  changes  are  likely  to  take  place  and  the  spread 
is  more  rapid,  becoming  practically  moist  gangrene,  and  the  patient  is  worn 
out  by  pain  and  septic  infection. 

Treatment.  Prophylaxis.  The  feet  of  old  persons  require  special  care 
where  the  circulation  is  defective,  as  indicated  by  neuralgic  pains,  slow  return 
of  colour  to  the  part  after  digital  compression,  &c.  They  should  be  pro- 
tected from  even  slight  injury,  as  tight  boots,  cutting  corns,  over-hot  bottles  ; 
warm  and  soft  footwear  is  essential.  Where  gangrene  has  actually  com- 
menced, if  the  area  is  small,  local  and  general  attention  in  the  shape  of 


GANGRENE  FROM  VASCULAR  CHANGES  63 

rest  in  bed,  aseptic  dressing,  warmth  applied  to  the  part,  massage  of  sur- 
rounding parts,  cardiac  stimulants  and  opium  to  relieve  pain  till  the  small 
slough  has  separated,  may  suffice  ;  but  where  the  condition  is  of  wider 
spread  more  radical  measures  will  be  indicated. 

Where  gangrene  is  rather  threatened  than  present,  as  shown  by  absence 
of  pulses,  discoloured  patches  of  the  skin,  &c,  an  attempt  may  be  made 
to  improve  the  circulation  by  performing  arterio-venous  anastomosis  or 
diverting  the  arterial  stream  into  a  vein  well  above  the  part  of  the  artery 
where  the  circulation  is  impeded.  A  lateral  anastomosis  of  the  femoral 
artery  and  vein,  together  with  tying  the  vein  above  the  anastomosis,  seems 
to  be  the  method  of  election.  Such  measures  have  proved  successful  in 
some  cases  of  this  nature,  but  rather  in  gangrene  due  to  endarteritis  in  the 
young  and  middle-aged  than  in  senile  gangrene  proper.  If  such  anastomosis 
and  reversal  of  the  circulation  fails  the  process  of  gangrene  will  be  hastened, 
so  this  operation  must  not  be  lightly  undertaken  and  only  in  carefully 
selected  cases.  Where  the  part  involved  in  gangrene  is  larger  than  a  single 
toe,  the  process  of  separation  of  the  slough  is  tedious  and  painful  and 
depresses  the  vitality  to  such  an  extent  that  amputation  well  above  the 
gangrenous  part  is  advisable  before  the  patient  becomes  too  weak  from 
pain,  loss  of  sleep,  and  toxic  absorption.  This  applies  also  in  cases  where 
arterio-venous  anastomosis  fails  to  relieve  the  condition.  In  a  few  cases 
amputation  of  the  foot  by  Syme's  method  may  suffice,  but  as  a  rule  the 
amputation  is  best  done  above  the  knee  either  in  the  lower  one-third  of  the 
thigh  or  by  Stokes's  supra-condylar  method. 

(b)  Post-febrile  Gangrene  from  Endarteritis,  after,  e.g.  enteric 
fever,  is  similar  to  the  senile  type  and  usually  dry  to  begin  with. 
As  regards  treatment,  arterio-venous  anastomosis  should  be  considered. 
When  amputation  is  needed,  such  patients,  being  younger  and  having  a 
better  general  circulation  than  the  subjects  of  real  senile  gangrene,  are 
more  suitable  for  low  amputations,  such  as  Syme's,  than  the  latter  group. 

(c)  Diabetic  Gangrene.  This  occurs  in  the  type  of  diabetes  or  glyco- 
suria found  in  stout  middle-aged  persons,  and  not  in  the  more  rapidly 
progressing  diabetes  of  young  adults.  In  such  cases  there  are  always  arterial 
changes  of  an  obstructive  nature,  and  the  vitality  of  the  tissues  in  addition 
is  lowered  by  the  presence  of  sugar  or  other  products  of  the  disease,  such 
as  acetone. 

Gangrene  in  these  cases  is  likely  to  originate  more  suddenly  than  in 
the  senile  form,  without  warning  pains  and  obviously  bad  circulation. 
Often  the  gangrene  can  be  traced  to  slight  injuries,  as  in  the  former  con- 
dition ;  it  may  be  localised  to  a  small  part,  but  is  more  likely  to  spread 
rapidly  and  assume  the  moist  form. 

Treatment.  Occasionally  expectant  treatment  may  be  employed  in  the 
form  of  local  aseptic  measures,  moderate  warmth  to  the  part,  rest  in  bed, 
and  treatment  of  the  diabetic  state,  which  should  not  be  too  drastic  or 
matters  will  be  made  worse ;  carbohydrates  should  be  only  moderately 
limited  and  codeia  or  opium  given  internally,  as  well  as  large  doses  of 


64  A  TEXTBOOK  OF  SURGERY 

bicarbonate  of  soda,  if  their  is  much  acetone  and  diacetic  acid  in  the  urine. 
Arterio-venous  anastomosis  is  out  of  the  question  in  such  patients.  Ampu- 
tation will  be  the  general  treatment,  through  the  lower  pan  oi  the  thigh. 
Special  care  is  needed  in  administering  anesthetics  to  these  patients  Bince 
the  already  present  acidosis  may  lie  greatly  increased  and  fatal  coma  result. 
Chloroform  is  absolutely  contra-indicated,  and  ether  is  not  very  safe.  Gas 
and  oxygen  or  spinal  ainesthesia  should  be  employed,  and  full  closes 
of  sodium  bicarbonate  (60  Lrrs.  four-hourly)  be  given  before  and  alter 
operation. 

li')  Gangrene  due  to  Arterial  Spasm,  (a)  Raynaud's  disease.  In 
this  disease  there  is  spontaneous  intermittent  spasm  of  the  peripheral 
arteries  of  the  extremities,  resulting  in  lecal  anaemia,  especially  found  in  the 
ringers,  toes,  nose,  and  ears.  In  the  early  stages  these  parts  become  white 
(syncope)  or  purplish-blue  (asphyxia)  ;  later,  with  greater  interference  to 
the  circulation,  necrosis  of  the  tissues  takes  place,  and  the  affected  parts 
undergo  gangrene  of  the  dry  type. 

Treatment.  When  affecting  the  ear-tips,  local  asepsis  till  the  small 
sloughs  separate  is  enough,  but  when  larger  parts,  as  fingers,  are  affected, 
the  part  is  kept  aseptic  till  a  line  of  demarcation  is  formed,  and  then  matters 
may  be  accelerated  by  amputation  close  above  this.  General  and  preventive 
treatment  is  in  the  hands  of  physicians. 

(b)  Gangrene  from  Ergot- poisoning.  This  is  not  unlike  the  last  type. 
It  occurs  but  rarely  from  medicinal  administration  of  the  drug,  but  usually 
from  eating  rye-bread  infected  with,  the  ergot  fungus  ;  fingers,  toes,  and  the 
tips  of  ears  and  nose  are  affected.  The  treatment  is  as  for  gangrene  in 
Raynaud's  disease. 

(3)  Embolic  and  Thrombotic  Gangrene.  Obstruction  to  an  artery 
of  a  limb  will  not,  as  a  rule,  cause  gangrene  owing  to  the  good  anastomotic 
circulation.  If,  however,  the  circulation  is  enfeebled  by  disease  of  the  heart 
or  prolonged  fevers,  &c.,  gangrene  may  follow  arterial  embolus.  Thus  an 
embolus  of  the  brachial  artery  may  lead  to  gangrene  of  some  of  the  fingers. 
Such  gangrene  is.  at  any  rate  initially,  of  the  dry  variety. 

Treatment.  Where  peripheral  embolism  is  diagnosed  from  sudden  pain 
with  pallor  and  loss  of  the  pulse  below  this  point,  the  affected  vessel  should 
be  explored,  the  embolus  extracted,  and  the  vessel  sutured — since,  even  if 
the  sutured  artery  becomes  thrombosed,  some  time  will  be  given  while  this 
is  taking  place  for  anastomotic  circulation  to  be  well  established,  and  the 
patient  is  no  worse  off  than  he  was  before,  with  the  artery  occluded.  When 
the  process  of  gangrene  is  well  established  we  can  generally  wait  for  a  line 
of  demarcation  to  become  established  and  amputate  close  above  this. 
\\  here  the  artery  is  of  the  terminal  variety,  e.g.  in  the  brain  or  kidney, 
there  being  usually  no  infection,  aseptic,  anaemic  necrosis  will  take  place 
and  a  fibrous  scar  result.  In  the  case  of  the  intestine  the  necrosed  tissues 
will  soon  be  invaded  by  micro-organisms  and  acute,  moist  gangrene  take 
place,  demanding  instant  operation  and  removal  of  the  gangrenous  portion 
of  the  gut,  if  possible. 


INFECTIVE  GANGRENE  65 

(c)  Infective  or  Microbic  Gangrene.  This  may  arise  from  infection 
with  very  virulent  organisms,  e.g.  streptococci,  causing  a  severe  inflammatory 
reaction.  The  tissues  are  destroyed  partly  by  toxines,  partly  bv  deficient 
blood-supply,  which  is  impaired  owing  to  pressure  on  the  vessels  from 
inflammatory  oedema  and  obstruction  of  the  vessels  from  thrombosis,  which 
are  phenomena  of  severe  inflammatory  reactions.  In  some  cases  the 
infecting  organism  is  relatively  virulent  owing  to  the  depressed  condition 
of  the  patient,  from  insufficient  food,  chronic  alcoholism,  active  syphilis,  &c. 
In  other  cases,  again,  the  organism  is  not  extremely  virulent  but  has  good 
opportunities  from  local  conditions  ;  thus,  in  cases  of  gangrene  following 
injuries  where  much  tissue  has  been  destroyed,  such  organisms  as  the 
Bacillus  Aerogenes  Capsulatus  can  obtain  a  footing  and  produce  gangrene. 
The  really  severe  types  of  spreading  gangrene  arising  from  injuries  are  due 
rather  to  such  infections  than  to  damage  of  tissues  and  blood-vessels. 
Finally,  a  mixed  infection  is  often  responsible,  as  streptococci  mixed  with 
B.  Aerogenes  or  with  the  spirochete  of  syphilis. 

Clinically  several  distinct  types  of  infective  gangrene  are  noted,  but 
there  is  considerable  uncertainty  as  to  their  specific  origin,  i.e.  whether 
they  are  due  each  to  separate  organisms  or  whether  the  same  type  of  gangrene 
may  be  due  to  various  organisms  pure  or  mixed,  and  whether  the  differences, 
when  present,  are  due  rather  to  the  different  response  of  various  parts  of 
the  body.  Thus  in  bones  occurs  acute  osteomyelitis  or  acute  necrosis, 
rapid  destruction  of  bone,  mostly  due  to  staphylococcal  infection  ;  in  the 
mouth  we  find  Cancrum  oris,  in  the  vulva  Noma  ;  in  the  skin,  boils  and 
carbuncles,  which  are  described  in  the  sections  on  Infections  and  Regional 
Surgery.  There  remain  to  be  considered  closely  allied  conditions  usually 
affecting  the  limbs  and  known  as  Spreading  or  Infective  Gangrene.  Spread- 
ing infective  gangrene — also  described  as  malignant  oedema,  acute  spreading, 
acute  emphysematous,  *spreading  traumatic  gangrene,  or  gangrene  fou- 
droyante — may  arise  from  small  local  infections  such  as  scratches,  followed 
by  spreading  cellulitis,  but  more  often  results  from  severe  injuries,  such 
as  crushes  or  compound  fractures  with  much  laceration  of  the  skin  and 
pulping  of  the  tissues.  The  part  affected  shows  at  the  onset  signs  of  acute 
inflammation,  great  redness,  and  cedematous  swelling ;  the  redness  soon 
changes  to  purple  and -black,  blebs  containing  foul  serum  appear  on  the 
surface,  and  greenish  or  brownish  discolorations  appear.  The  swelling  of 
the  limb  increases  from  the  development  of  gases  in  the  tissues,  and  on 
palpation  crepitation  can  be  perceived.  The  signs  of  local  death  are  soon 
noted — loss  of  pulse,  heat,  and  sensation — the  pain,  which  at  first  may  be 
great,  disappearing.  The  process  spreads  rapidly  up  the  limb,  advancing 
some  inches  in  twenty-four  hours,  while  constitutional  signs  are  marked — high 
fever  and  rigors  or,  in  very  severe  cases,  subnormal  temperature  and  grave 
collapse.  In  these  cases  the  tissue-changes  are  largely  due  to  the  spread 
of  toxines,  developed  by  the  organisms  at  the  site  of  injury  or  infection,  the 
organisms  themselves  spreading  more  slowly.  Thus  in  a  case  of  emphyse- 
matous gangrene,  developing  after  four  compound  fractures  of  the  arm 
1  5 


66  A  TEXTBOOK  OF  SURGERY 

and  forearm,  the  forearm  became  rapidly  purple  and  black,  crepitating  and 
lifeless  to  the  elbow,  while  oedema  and  redness  extended  to  the  shoulder 
and  front  of  the  chest.  As  the  gangrene  was  rapidly  spreading,  amputation 
at  the  shoulder-joint  was  performed.  We  noted  that  the  muscles  at  the 
site  of  amputation  were  oedematous,  brownish  in  colour,  and  smelt  mouldy, 
and  considered  that  prognosis  was  hopeless.  Nevertheless  the  patient 
recovered  and  the  wound  healed  by  practically  first  intention,  showing  that 
the  tissues  cut  through,  though  appearing  to  be  on  the  verge  of  gangrene, 
were  only  suffering  from  the  effect  of  toxic  absorption  and  not  from  infection. 
Various  organisms  are  found  in  these  infections,  including  the  bacillus  of 
malignant  oedema,  an  anaerobic  organism  of  great  virulence;  recent  work, 
however,  tends  to  prove  that  the  most  usual  organism  is  the  Bacillus 
A>Togenes  Capsulatus,  which  is  of  relatively  low  malignancy,  and  anaerobic 
but  growing  only  on  dead  or  dying  tissues,  which  have  been  reduced  as 
regards  resistance  by  injury  or  infection  with  other  organisms  such  as 
streptococci.  The  toxines  of  this  organism,  however,  seem  to  be  very 
poisonous. 

Treatment.  Prophylaxis  consists  in  removing  dead  portions  of  tissue 
when  cleaning  lacerated  wounds,  thus  removing  suitable  pabulum  for  these 
organisms  and,  bearing  in  mind  the  fact  that  they  are  anaerobic,  keeping 
such  wounds  open  and  using  irrigation  with  peroxide  of  hydrogen  (of  ten 
volumes  strength)  or  permanganate  of  potash,  to  inhibit  their  growth. 
Where  gangrene  has  actually  commenced  no  time  is  to  be  lost.  Smears 
from  the  discharge  of  the  wound  or  the  blebs  should  be  quickly  examined 
bacteriologically.  and  if  the  bacillus  of  malignant  oedema  is  found,  ampu- 
tation at  once  performed  at  least  six  inches  higher  than  the  gangrenous 
area  ;  but  if  the  chief  organism  is  found  to  be  B.  aerogenes,  drastic  local 
treatment  may  be  tried,  the  parts  laid  freely  open  with  long,  deep  incisions 
and  the  resulting  wounds  washed  out  repeatedly  with  hydrogen  peroxide, 
which  may  quell  the  infection.  Success  has  attended  this  treatment,  but 
if  the  infection  has  spread  through  the  deep  fascia  the  prospects  are  less 
hopeful  than  while  it  is  still  superficial.  The  line  of  advance  of  the  gan- 
grenous part  should  be  carefully  watched,  and  if  not  remaining  stationary 
after  twenty-four  hours,  high  amputation  should  be  performed — i.e.  if 
gangrene  involves  the  hand,  amputation  about  the  elbow-joint ;  if  the 
spread  is  above  the  elbow,  amputation  through  the  shoulder-joint.  In 
the  case  of  the  foot,  amputation  about  the  knee  by  Stokes's  method.  Where 
the  gangrene  is  above  the  knee,  amputation  through  the  thigh  as  high  as 
possible  would  seem  better  practice  than  disarticulation  at  the  hip-joint, 
since  the  shock  of  the  last  operation  is  considerably  greater,  and  it  should 
be  avoided  where  possible  in  patients  already  greatly  depressed  by  toxaemia. 
Spinal  anaesthesia  and  nerve  blocking  are  useful  in  such  cases. 

Hospital  Gangrene  or  Phagedena.  This  sequel  to  wounds  and 
operation,  common  in  the  pre-antiseptic  days,  is  now  hardly  seen  except 
in  neglected  cases,  e.g.  the  penis,  where  a  mixed  infection  of  syphilis  and 
some  pyogenic  infection  has  been  untreated  for  some  days.     Phagedena 


PHAGEDENA  67 

consists  in  gangrene  spreading  from  a  wound  or  ulcer,  less  rapidly  than  in 
the  type  described  in  the  last  section,  but  still  sufficiently  rapidly  to  demand 
drastic  treatment.  Various  organisms  are  responsible.  The  edges  of  the 
wound  or  ulcer  become  converted  into  grey  sloughs,  melting  away  with  foul, 
thin,  blood-stained  discharge,  and  give  rise  to  a  rapidly  spreading  ulcer ; 
constitutional  signs — fever  and  general  depression — are  usually  severe. 
Treatment  consists  in  free  excision  of  the  gangrenous  part  and  application 
of  pure  carbolic,  following  irrigation  with  hydrogen  peroxide  (ten  volumes) 
or  chlorine-water  ;  frequent  change  of  moist  antiseptic  dressings,  such  as 
cyanide  gauze  wrung  out  of  biniodide  of  mercury,  1  in  2000,  soaking  in  a  bath 
of  lysol  (15  minims  to  a  pint  of  water),  will  generally  result  in  the  production 
of  an  aseptic  wound,  but  in  some  cases  amputation  will  be  needed.  The 
conditions  carbuncle,  noma,  cancrum  oris  are,  in  severity  and  spread,  not 
unlike  phagedena  ;  these  are  described  in  later  sections. 


CHAPTER  VI 

I.  NEW  GROWTHS.     II.  CYSTS 

Classification,  Innocent  and  Malignant  :  Classification  from  origin  and  from 
structure  :  .Etiology  :  Irritation,  parasites,  "rests"  :  Local  and  general 
malignancy  :  Metastasis  and  their  methods  of  formation  :  Teratomas  :  Der- 
moids :  Mixed  tumours  (renal,  salivary)  :  Blastomas  :  Chorio-epithelioma  : 
LEru>oM\s  :  Papillomas  :  Adenomas  :  Cancers  :  Transitional  lepidomas  : 
Mesotheliomas  :  Endotheliomas  :  Angeiomas  :  Melanomas  :  HYLOMAS  :  Neu- 
romas :  Fibromas  :  Lipomas  :  Chondromas  :  Osteomas  :  Tumours  of  bone- 
marrow  :  Myomas  :  Myxomas  :  Sarcomas  :  Diagnosis  of  tumours  :  Treatment. 
Cysts — embryonic,  inflammatory,  parasitic,  glandular,  degeneration. 

I.  New  Growths 

These  foiuiations  are  also  known  as  tumours  or  neoplasms.  A  new 
growth  may  be  denned  (C.  P.  White)  as  "  a  mass  of  cells,  tissues, 
or  organs  resembling  those  normally  present  but  arranged  atypically, 
growing  at  the  expense  of  the  organism  without  at  the  same  time 
serving  any  useful  function  "' — or,  in  other  wrords,  a  part  or  parts  of 
the  body  assume  the  property  of  independent,  parasitic  and  selfish 
growth. 

The  variety  of  such  neoplasms  is  very  great  and  many  sorts  hardly  come 
into  surgical  cognizance,  but  a  short  review  of  the  whole  class  may  serve  to 
give  a  better  idea  of  their  true  nature  and  mode  of  life,  since,  at  best,  it 
must  be  confessed  that  our  knowledge  of  the  real  underlying  principles  of 
these  formations  is  vague  and  nebulous. 

Classification  of  new  growths  is  by  no  means  easy.  From  a  practical 
standpoint  the  obvious  division  is  into  :  (a)  Innocent,  where  the  growth 
is  local  and  remains  so,  although  growing  larger  indefinitely  ;  (b)  malignant, 
in  which  the  growth  invades  the  body  of  the  organism  or  host,  either  by 
local  infiltration  or  by  passing  along  body  channels  such  as  arteries,  veins, 
Lymphatics,  peritoneum,  pleura,  &c. 

Classification  of  tumours  according  to  structure  and  development  is 
also  of  value  not  only  from  the  scientific  aspect,  as  helping  to  standardize 
the  real  nature  of  these  growths,  but  also  because  from  their  structure  we 
can  often  form  some  idea  of  the  course  and  prognosis  of  the  tumour  and 
the  sort  of  treatment  necessary — i.e.  whel  her  no  treatment  or  local  excision 
will  suffice  or  whether  some  large  operation,  removing  much  surrounding 
tissue  and  the  area  of  lymphatic  drainage,  will  be  necessary  to  give  a  reason- 
able prospect  of  complete  cure. 

68 


NEW  GROWTHS  69 

CLASSIFICATION   OF    TUMOURS  ACCORDING    TO   THEIR  ORIGIN 

The  point  of  origin  of  a  neoplasm  will  curtail  its  possibilities  for  growth, 
Thus  fully  developed  cells,  such  as  the  surface  epithelium,  liver  cells,  &c, 
can  only  produce  cells  resembling  themselves  even  where  such  production 
is  atypical,  as  is  the  case  in  new  growths.  Such  cells  are  called  Unipotent 
(Barfurth).  Passing  back,  however,  in  the  history  of  the  organism,  we 
arrive  at  a  time  when  certain  cells  have  the  power  of  producing  several  quite 
different  types  of  cells  in  their  natural  process  of  division,  i.e.  they  can 
specialise  in  their  descendants.  For  example,  the  lateral  cell  mass  or 
primitive  myotome  of  the  embryo  gives  rise  to  kidney,  muscle,  and  skeletal 
cells  (of  vertebra?  and  ribs)  ;  such  cells  are  called  Pluripotent,  and  should 
they  take  on  neoplastic  growth,  the  tumour  derived  from  them  will  contain 
any  structure  to  which  the  primitive  cells  could  give  rise.  Still  farther  back 
in  developmental  history  are  the  cells  Avhich  contain  in  their  being  the 
potentialities  of  a  complete  organism,  e.g.  the  fertilized  ovum,  the  primordial 
blastomeres  derived  by  its  division,  and  the  germ-cells  of  the  ovary  and 
testis  from  which  the  ova  and  spermatozoa  originate.  Such  cells  are  called 
Totipotent,  and  when  taking  on  neoplastic  development  give  rise  to  tumours 
which  may  contain  any  or  all  parts  of  the  complete  organism. 

In  this  way,  following  Adami,  we  may  divide  new  growths  into  : 

(1)  Teratomas  or  tumours  derived  from  totipotent  cells,  amongst  which 
are  included  such  different  conditions  as  conjoined  twin  monsters,  foetal 
inclusions  (part  of  one  foetus  included  in  another),  ovarian  and  testicular 
dermoids,  sacral  teratomas,  &c.  Note,  these  neoplasms  may  be  obvious 
at  birth  as  monsters  and  sacral  teratomas,  or  the  included  part  may  remain 
latent  for  a  variable  time,  becoming  noticed  only  when  it  has  grown  to  some 
considerable  size,  as  is  the  case  with  ovarian  teratomas  or  dermoids. 

(2)  Teratoblastomas  or  Mixed  tumours,  which  are  derived  from 
pluripotent  cells  of  the  individual  and  best-known  in  renal  tumours  and  the 
mixed  growths  of  the  parotid  and  submaxillary  glands. 

(3)  Blastoma  is  the  term  applied  to  tumours  derived  from  unipotent 
cells  and  includes  most  tumours  of  practical  import,  both  innocent  and 
malignant.     These  may  further  be  divided  into  : 

(a)  Heterochthonous  or  teratogenous,  in  which  the  cells  of  the  growth 
are  derived  from  another  individual :  of  these  chorio-epithelioma  forms 
the  best  example. 

(b)  Autochthonous,  where  unipotent  cells  of  the  individual  itself  assume  a 
parasitic  nature,  including  most  other  blastomas. 

CLASSIFICATION  FROM  STRUCTURE 
The  most  satisfactory  division  appears  to  be  that  given  by  Adami, 
which  is  based,  not  only  on  the  structure,  but  also  on  the  ancestry  of  the 
cells  and  tissues  implicated  in  tumour-formation  ;  so  that  this  classification 
becomes  an  amplification  of  the  embryonic  classification  above  detailed 
and  applied  to  the  blastomas. 


To  A  TEXTBOOK  OF  SURGERY 

In  the  firs!  place,  normal  tissues  may  be  considered  as  belonging  to 
two  main  groups. 

A.  Lepidic,  rind,  or  (practically)  epithelial  tissues. 

B.  Hylic,  pulp,  or  tissues  other  than  epithelial,  including  the  connective 
tissues  and  similarly  formed  structures. 

A.  LEPIDIC  TISSUES  are  those  in  which  there  is  no  definite  stroma 
between  the  individual  cells  nor  blood-  or  lymph-vessels,  though  stroma  of 
mesenchymatous  origin  may  intervene  between  groups  of  cells.  Such  cells 
are  arranged  in  one  or  more  layers  on  a  basis  of  stroma  either  spread  out 
as  an  epithelium  or  endothelium  or  arranged  in  alveoli  as  in  glands.  Such 
tissues  may  be  sprung  from  : 

(a)  Epiblast,  e.g.  epidermis,  hairs,  sweat  and  sebaceous  glands,  the  lens 
of  the  eye. 

(b)  Hypoblast,  e.g.  the  epithelium  of  the  digestive  tract  and  glands  leading 
into  it.  as  the  liver,  pancreas,  thyroid,  lungs,  &c. 

(c)  Mesothelium  (i.e.  the  lining  of  the  ccelome  or  primitive  body  cavity 
which  is  a  split  in  the  mesenchyme),  including  the  lining  cells  of  the  pleura, 
peritoneum,  and  cells  of  the  testis,  kidney,  ovary,  uterus,  and  Fallopian 
tubes. 

(d)  Endothelium,  or  lining  of  blood-vessels  and  lymphatics. 

B.  Hylic  or  pulp  tissues  are  those  in  which  the  specific  cells  lie  in  a 
definite  stroma  which  may  be  homogeneous,  granular,  or  fibrillated,  and 
often  contains  blood-  and  lymph-vessels  ;  these  tissues  may  originate  from  : 

(a)  Epiblast,  e.g.  the  nerve-cells  and  neuroglia. 

(b)  Hypoblast.    The  only  example  being  the  notochord. 

(c)  Mesenchyme  or  mesoblast,  e.g.  connective  tissue,  bone,  bone-marrow, 
fat,  cartilage,  involuntary  muscle,  blood-corpuscles. 

id)  Mesothelial.     Striated  muscle  is  the  only  example. 

We  may,  then,  divide  tumours  into  (a)  those  derived  from  lepidic  or 
rind  tissues  or  lepidomas  and  (b)  those  formed  of  hylic  tissues  or  hylomas 
— the  cells  having  in  the  former  case  the  arrangement  of  those  described  as 
lepidic,  or  without  intervening  stroma  ;  in  the  latter  the  hylic  arrangement 
where  stroma  is  present.  Finally,  the  neoplasms  thus  derived  may  closely 
resemble  in  the  character  of  their  cells  the  tissue  from  which  they  are 
sprung,  when  they  are  called  typical  (clinically  "  innocent  "),  or  may 
deviate  in  a  varying  manner  from  their  ancestral  cells,  when  they  deserve 
the  title  atypical  (clinically  "  malignant  "). 

Stroma  of  Neoplasms.  This  is  derived  in  the  first  instance  from  the 
tissues  of  the  host,  viz.  connective  tissue,  blood-  and  lymph-vessels,  which 
surround  the  mass  of  new  growth  and  supply  it  with  nourishment.  The 
stroma  may  retain  the  properties  of  normal  tissues  or  undergo  secondary 
changes  in  i  he  direction  of  becoming  atypical  or  malignant,  so  that  in  some 
instances  we  find  t  he  stroma  as  well  as  the  specific  cells  of  a  tumour  assuming 
a  malignant  appearance.  Where  the  cells  of  the  tumour  are  set  in  layers 
on  the  stroma  or  arranged  in  alveoli  but  without  penetration  of  stroma  in 
between  individual  cells,  we  have  the  type  lepidoma,  of  which  papillomas 


CLASSIFICATION  OF  TUMOURS  71 

and  adenomas  represent  benign  or  typical  varieties  and  carcinomas  the 
malignant  type.  Where  the  cells  of  the  growth  are  intimately  mingled  with 
the  stroma,  which  penetrates  between  individual  cells  and  forms  part  of 
the  tumour  proper,  the  condition  is  described  as  hyloma,  and  where  typical 
or  innocent  is  represented  by  fibroma,  osteoma,  &c.  ;  where  atypical  or 
malignant,  by  sarcoma. 

In  other  words,  lepidomas  are  epithelial  tumours,  using  the  term  epithe- 
lium in  the  widest  sense,  whether  derived  from  epiblast,  hypoblast,  or 
mesoblast,  including  endo-  and  meso-thelium. 

Hylomas  are  tumours  often  of  connective  tissue  or  of  very  similar 
structure,  usually  of  mesoblastic  origin,  but  also  epithelial  and  even  hypo- 
blastic  (in  the  rare  chordoma). 

Moreover,  in  certain  growths  there  is  a  tendency  for  lepidic  tumours  to 
assume  a  hylic  form  of  growth,  especially  when  derived  from  meso-  or  endo- 
thelial cells,  and  such  tumours  are  called  "  transitional  lepidomas."  Similar 
transition  of  cells  is  also  found  occasionally  in  other  lepidomas,  e.g.  in  cancer 
of  the  breast  it  is  sometimes  difficult  to  say  whether  some  of  the  cells  at  a 
distance  from  the  growing  edge  are  epithelial  or  derived  from  the  stroma. 
On  these  lines  the  following  classification  of  new  growths  may  be  adopted  : 

(1)  Teratomas,  including  ovarian  dermoids,  some  testicular  tumours,  &c. 

(2)  Teratoblastomas,  including  mixed  tumours  of  the  parotid  and 
kidney. 

(3)  Blastomas,  consisting  of  : 

(a)  Heterochthonous,  of  which  chorio-epithelioma  is  the  common 
example. 

(6)  Autochthonous,  which  are  further  divided  into  : 

A.  Lepidomas,  of  the  following  origin  : 

(1)  Epiblastic.     (a)  Typical:     Papillomas,  adenomas. 

(6)  Atypical :  Squamous-celled  carcinoma  (epithelioma)  and  cancer  of 
epithelial  glands. 

(2)  Hypoblastic.  (a)  Typical :  Adenoma,  papilloma  of  gut,  bladder, 
thyroid,  &c. 

(6)  Atypical :  Carcinoma  of  these  organs. 

B.  Transitional  Lepidomas,  i.e.  lepidic  tumours,  often  showing  hylic 
or  sarcomatous  structure  in  parts,  originating  as  follows  : 

(3)  Mesothelial.  (a)  Typical :  Adenoma  of  the  kidney,  testis,  ovary, 
prostate,  &c. 

(b)  Atypical :  Cancers  of  the  above  organs,  squamous  endothelioma  of 
serous  surfaces,  hypernephromas  (Grawitz  tumours  or  renal  mesothelioma). 

(4)  Endothelial,  (a)  Typical :  Simple  angeiomas  of  blood-  and  lymph- 
vessels. 

(&)  Atypical :  Peritheliomas,  spreading  endothelioma,  vascular  sar- 
comas, &c. 

C.  Hylomas,  derived  from  : 

(5)  Epiblast.     (a)  Typical :   True  neuroma,  glioma. 
(b)  Atypical  :  Gliosarcoma. 


72  A  TEXTBOOK  OF  SURGERY 

(6)  Hypoblast.  Chordoma  or  tumourof  the  notochord,  which  may  be 
typical  or  atypical. 

(7)  Mesenchyme,  (a) Typical:  Fibroma,  lipoma, chondroma,  osteoma, 
&c. 

(/>)  Atypical  :  Sarcomas  of  all  sorts. 

(8)  Mesothelium.     Rhabdomyoma  or  tumour  of  striped  muscle. 

ETIOLOGY   AND   CAUSATION  OF   NEW   GROWTHS 

We  arc  still  in  the  dark  as  to  why  certain  cells,  tissues,  or  organs  of  the 
embryo  or  adult  take  on  parasitic  growth,  and  can  only  mention  certain 
causes  which  sometimes  lead  to  this  condition  and  briefly  discuss  a  lew 
theories  as  to  the  nature  of  neoplastic  growth  ;  nor  is  it  certain  that  the 
same  cause  is  at  the  root  of  every  sort  of  new  growth,  i.e.  whether  new 
growths  are  always  conditions  of  the  same  order.  Thus  there  is  nothing 
obviously  relating  an  ovarian  dermoid  to  a  squamous-celled  cancer  of  the 
lip. 

The  most  certainly  known  antecedent  to  new  growth  is  injury  of  various 
kinds.  Such  injury  may  be  gross  trauma — such,  for  instance,  as  bruising 
of  tissues,  fractures  of  bones,  which  seem  in  a  few  instances  to  be  undoubtedly 
the  cause  of  new  growths  (Coley).  More  usual  as  causes  are  minor,  repeated 
insults  by  irritating  substances,  whether  particulate  as  soot  or  liquid  and 
volatile,  as  certain  tar-products,  which  cause  inflammatory  reaction  of  the 
skin,  ending  in  the  production  of  papillomats  (warts)  and  cancer,  as  in 
chimney-sweep's  cancer  of  the  scrotum,  or  the  chronic  eczema  which  appears 
on  the  face  and  arms  of  those  who  work  in  tar  distilleries,  which  often  ends 
in  cancer  ;  a  similar  condition  is  the  irritation  of  the  glans  penis  by  secre- 
tions retained  under  a  tight  foreskin,  which  may  in  course  of  time  lead  to 
cancer  of  the  glans  ;  or  the  irritation  of  a  clay-pipe,  which  so  often  is  the 
immediate  cause  of  cancer  of  the  lip  or  tongue.  There  must,  however,  be 
something  else  at  work  besides  mere  irritation  to  account  for  the  formation 
of  cancer,  whether  this  is  in  the  specific  nature  of  the  irritant  or  in  the  tissues 
themselves,  since  in  some  situations  lifelong  irritation  does  not  lead  to  new 
growth,  or  at  any  rate  not  the  more  free-growing  parasitic  forms  ;  thus  the 
feet  of  millions  are  irritated  by  ill-fitting  boots,  and  corns  (papillomas)  in 
this  situation  are  common,  yet  cancer  starting  such  a  situation  is  practically 
unknown.  Instances  allied  to  the  above  are  those  of  narrow  straits  in 
tubular  structures  where  the  passage  of  normal  products  may  in  time  cause 
irritation  and  formation  of  new  growth,  such  as  the  (esophagus  (where 
cancer  commences  in  the  narrower  parts),  the  pylorus,  rectum,  aims,  os 
uteri,  &c.  The  irritation  of  calculi  furnish  further  examples,  the  presence 
of  such  foreign  bodies  being  sometimes  responsible  for  cancer  of  the  kidney 
or  gall-bladder. 

The  frequent  occurrence  of  new  growths  in  scars,  especially  those  of  a 
tuberculous  origin,  such  as  healed  lupus,  may  be  explained  as  the  effect  of 
the  irritation  of  past  infection  or  as  the  result  of  a  weakening  of  the  tissues, 
which  renders  them  more  prone  to  undergo  neoplastic  changes. 


.ETIOLOGY  OF  TUMOURS  73 

Age  Incidence.  This  varies  with  the  type  of  tumour.  The  lepidic 
formations  occur  chiefly  in  the  subjects  of  middle  or  old  age,  while  the 
hylomas  are  more  frequent  in  the  young,  but  there  are  many  notable 
exceptions. 

THEORIES   OF   CAUSATION   OF   NEW   GROWTHS 

(a )  The  Parasitic  Theory.  From  time  to  time  various  bodies  are  found 
inside  the  cells  of  new  growths  with  special  staining  reactions,  which  have 
been  regarded  as  parasites.  Such  bodies  always  turn  out  on  closer  investi- 
gation to  be  products  of  cell-degeneration.  Organisms  such  as  cocci  have 
been  cultivated  from  new  growths,  but  in  no  case  will  these  reproduce  the 
original  disease,  and  are  simply  epiphenomena  or  contaminations  from 
faulty  bacteriological  technique.  The  spread  of  cancer  by  blood  and 
lymph  channels  and  its  general  invading  tendency  certainly  resemble  the 
spread  of  infective  disease,  but  the  secondary  deposits  found  in  the  infective 
diseases  are  due  to  local  inflammatory  reaction,  whereas  the  metastatic 
deposits  of  cancer  or  sarcoma  are  built  up  of  descendants  of  the  original  cells 
of  the  growth.  The  disease  is  only  parasitic  and  infective  in  the  sense  that 
certain  cells  have  taken  on  a  parasitic  existence  at  the  expense  of  the  rest 
of  the  body,  and  not  that  it  is  caused  by  external  parasites  of  separate  origin . 
Apparent  exceptions  to  this  statement  are  : 

1.  That  of  chorio-epithelioma,  in  which  part  of  the  foetal  tissues  become 
parasitic  in  the  mother. 

2.  The  success  of  experimental  grafting  of  cancer  in  mice,  whereby  cancer 
can  be  transferred  from  one  mouse  to  another  in  much  the  same  manner 
that  infective  disease  is  inoculated. 

There  is  no  evidence  to  show  that  these  cells  are  other  than  cells  originally 
forming  part  of  an  animal  of  the  same  species  as  that  infected  and  of  quite 
a  different  order  to  the  living  organisms  usually  called  parasites,  such  as 
bacteria  or  protozoa. 

(b)  The  Theory  of  Fcetal  Residues  (Cohnheim).  The  idea  in  this 
theory  is  that  various  residues  of  foetal  tissues  or  organs  are  left  scattered 
through  the  body  and  may  later  develop  into  tumours.  This  partly  explains 
the  structure  of  such  ovarian  and  other  teratomas  as  well  as  the  mixed 
tumours,  and  is  undoubtedly  true  up  to  a  point.  Although,  however,  the 
theory  explains  the  nature  and  manner  of  formation  of  such  growths,  it 
in  no  way  explains  their  origin  and  why  they  come  into  being  ;  nor  can  the 
generality  of  new  growths  be  explained  in  this  manner  at  all.  It  would 
need  a  powerful  imagination  to  explain  a  cancer  of  the  lip  or  scrotum  on 
embryological  grounds.  This  theory,  then,  only  explains  the  complexity 
of  certain  tumours  but  not  why  they  arise.  Most  of  the  other  theories  give 
no  explanation  whatever.  Thus  the  irregular  and  atypical  nuclear  division 
described  by  Von  Hansemann  as  "  anaplasia,"  and  which  is  akin  to  the 
division  normally  occurring  in  the  generative  cells,  gives  no  explanation  of 
the  reason  why,  but  is  simply  a  very  interesting  observation  of  the  process 
in  the  phenomenon  in  question  ;    moreover,  anaplasia    is    only  found  in 


71  A  TEXTBOOK  OF  SURGERY 

malignant  tumours.  Bashford's  view,  that  cell -proliferation  of  neoplastic 
nature  is  due  to  senility  or  old  age  of  the  cells  only  explains  certain  malignant 
growths.  Hauser's  idea  that  such  alterations  in  the  behaviour  of  cells  is 
a  biological  variation  or  "'sport."  though  possibly  true,  is  of  little  help. 
In  tine,  none  of  these  theories  are  at  present  of  practical  import,  save  only 
the  fact  that  prolonged  irritation  may  lead  to  malignant  growths.  To 
conclude,  we  may  question  whether  it  is  rational  to  locate  all  these  different 
conditions  together  as  neoplasms,  since  they  differ  so  much  in  structure  and 
(so  tar  as  can  be  seen)  in  causation.  Thus  an  ovarian  dermoid,  a  wart  (due 
to  irritation),  and  a  cancer  are  all  called  neoplasms  ;  but  it  might  be  more 
scientific  to  class  the  former  with  congenital  defects,  the  wart  with  inflam- 
matory or  reactive  phenomena  (Adami  uses  the  term  blastomatoid  in  this 
connexion),  while  the  latter  (cancer)  seems  more  justly  to  deserve  the  term 
new  growth,  and  yet  may  be  the  direct  lineal  descendant  of  a  wart. 

Turning  now  to  more  practical  matters,  we  must  consider  innocence  and 
malignancy. 

Innocent  or  Benign  Tumours.  A  tumour  is  said  to  be  innocent, 
benign,  or  non-invading  in  regard  to  its  relations  with  surrounding  structures. 
Such  formations  are  called  "  typical "  with  respect  to  their  cell  elements, 
which  are  fully  developed,  closely  resembling  those  of  the  tissue  from  which 
they  are  sprung  ;  the  blood-vessels  are  well  formed  and  degenerations  are 
relatively  uncommon.  In  general,  these  tumours  are  of  slow  growth,  often 
encapsuled ;  they  grow  locally,  only  displacing  the  surrounding  tissues ;  grow  1 1 1 
takes  place  throughout  the  tumour,  not  chiefly  at  the  edges,  as  in  malignant 
tumours.  They  do  not  form  secondary  deposits  at  a  distance  (metastases), 
are  often  easy  of  removal,  and  when  completely  removed  do  not  recur. 

The  term  innocence  applies  only  to  the  structure  of  tumours,  not  to  their 
position,  since  structurally  innocent  tumours  may  prove  lethal  if  not  removed, 
owing  to  their  action  on  important  structures,  such  as  the  brain,  trachea,  &c. 

Malignant  Tumours.  These  may  also  be  called  invading  or  infiltrating 
growths  from  their  manner  of  progress,  or  "  atypical  "  from  the  structure  of 
their  cell  elements,  which  depart  in  appearance  greatly  from  those  of  the 
normal  tissue,  to  which  they  trace  their  descent.  Such  atypical  cells  are 
embryonic  or  vegetative  in  character,  not  fully  or  properly  developed,  and 
differing  from  each  other  as  well  as  from  the  cells  of  the  uormal  tissue — 
having  great  and  rapid  power  of  growth,  often  assuming  most  strange  and 
bizarre  forms. 

Malignant  tumours  for  the  most  part  grow  rapidly  ;  there  is  little  attempt 
at  the  formation  of  a  capsule,  but  invasion  of  surrounding  tissues,  which 
may  be  visible  to  the  naked  eye  or  seen  on  microscopical  examination  (in 
cases  where  there  is  an  appearance  of  encapsulation).  The  cells  of  the 
growth  pass  readily  into  blood-  and  lymph-vessels  or  body  spaces  and  thus 
disseminate,  forming  "  metastases  "  or  secondary  deposits. 

In  malignant  tumours  growth  is  greatest  at  the  edge  (where  the  blood- 
supply  is  best)  ;  in  more  central  parts,  owing  to  poor  supply  of  blood  (depen- 
dent on  imperfect  formation  of  vessels  in  these  tumours),  growth  is  less 


MALIGNANCY 


75 


rapid  and  degenerations  are  very  common,  leading  to  formation  of  cysts, 
haemorrhages,  &c.  These  growths  frequently  recur  after  removal,  for  this 
is  often  imperfect,  since  the  outer  limit  of  the  growth  is  usually  far  in  advance 
of  any  macroscopic  changes  that  can  be  detected.  Where  such  growths  reach 
the  surface  they  will  bore 
through  with  ulceration 
and  fungation. 

Local  Malignancy. 
Some  tumours,  though  in- 
vading the  surrounding 
structures  locally  and  re- 
curring locally,  if  not  very 
widely  removed,  appear 
never  to  form  metastases ; 
such  are  the  carcinoma  of 
the  skin  known  as  rodent 
ulcer,  certain  sarcomas  of 
the  jaw  (epulis),  and  giant- 
celled  sarcoma  of  bone. 


GENERAL  SIGNS  OF 
MALIGNANCY 

(1)  Cachexia,  by  which 
is  meant  a  general  weak- 
ness and  wasting  of  the 
body,  the  complexion  be- 
ing sallow  and  earthy,  the 
skin  wrinkled  and  flaccid. 
This  condition  is  only  seen 
in  advanced  cases  of  malig- 
nant growth,  and  may  be 
due  to  poisoning  with  de- 
generation-products of  the 
tumour  or  by  destruction 
of  important  organs,  such  as  the  liver,  with  metastatic  deposits.  The 
degree  of  cachexia  is  very  variable  and  tells  little  about  the  extent  of  the 
growth,  but  almost  invariably  means  that  curative  treatment  by  operation 
is  out  of  the  question. 

(2)  Anamia  is  commonly  associated  with  malignant  growths,  but  only 
when  these  are  of  some  duration,  and  takes  the  character  of  a  secondary 
anaemia,  i.e.  anaemia  with  a  leucocytosis  of  polymorphonuclear  cells,  and, 
like  cachexia,  generally  implies  that  such  a  growth  is  beyond  cure  unless 
the  growth  is  producing  this  general  effect  from  its  local  action  on  some 
important  organ,  such  as  the  stomach. 

(3)  Metastases,  or  secondary  deposits  at  a  distance  from  the  original 
growth. 


Fig.  14.  Malignant  pouched  tumour,  showing  para- 
lysis of  the  lower  part  of  the  face  (loss  of  naso-labial 
tissue  and  drooping  of  the  angle  of  the  mouth)  from 
involvement  of  the  facial  nerve,  which  shows  the  infil- 
trating properties  of  the  growth. 


76  A  TEXTBOOK  OF  SURGERY 

These  are  the  results  of  the  development  of  cells,  derived  from  the 
original  tumour,  carried  to  distant  parts  by  the  blood-  or  lymph-streams. 
The  cells  of  metastases  are  not  Formed  locally,  as  is  the  exudation  of  cells 
When  a  tissue  reacts  to  an  infection,  though  in  addition  there  may  be  such 
a  tissue-reaction  or  local  inflammation,  which  leads  to  fibrosis  and  in  some 
cases  destruction  of  the  invading  parasitic  cells  and  is  a  natural  method  of 
cure. 

Metastases  arise  in  s  >veral  ways  : 

(1)  By  dissemination  along  the  lymphatics,  i.e.  as  emboli,  which  are 
detained  in  the  next  lymph-node—  the  latter  acting  as  a  filter  and  causing 
the  secondary  glandular  enlargement  so  characteristic  of  cancer. 

('2)  By  dissemination  through  serous  cavities,  e.g.  the  pleura  or  peri- 
toneum. 'I  hus  a  cancer  of  the  pylorus  \vill  in  time,  if  not  excised,  spread 
to  the  peritoneum,  and  some  cells  of  the  growth  may  become  detached  and 
pass  in  the  peritoneal  cavity  to  a  considerable  distance.  Thus  we  have 
felt  such  secondaries  in  the  pouch  of  Douglas,  causing  some  confusion  in 
diagnosis. 

(3)  The  "  seeding  "  of  a  papilloma  of  the  bladder,  where  we  may  find 
a  large  single  primary  growth  surrounded  by  a  number  of  small  "  seedlings," 
is  due  to  a  similar  process. 

(4)  Closely  allied  to  this  method  of  spread  is  metastasis  by  contact — 
"  contact  infection  "  ;  thus  cancer  may  be  transferred  from  one  lip  to  the 
corresponding  part  of  the  other  by  contact.  We  have  seen  a  cancer  of  the 
penis  cause  a  secondary  growth  of  the  scrotum,  where  it  came  in  contact. 

(5)  Dissemination  by  the  blood-stream  results  from  invading  cells 
|  enetrating  the  coats  of  vessels  and  being  carried  to  the  lung  (usually  in 
sarcomas). 

Apparent  metastases  or  growths  at  a  distance  are  often  due  to  "  permea- 
tion "  (Handley).  In  this  process  the  growth  spreads  along  the  tissue  planes 
via  the  smaller  lymphatics,  not  by  passage  of  emboli  in  the  lymph-stream 
but  as  solid  strands  of  cells  which  grow  along  these  paths  of  less  resistance 
and  at  various  points  suddenly  take  on  more  rapid  and  abundant  growth, 
often  at  some  distance  from  the  original  tumour.  The  thin  intervening 
strands  of  invading  cells  become  destroyed  by  the  inflammatory  fibrosis 
occurring  in  the  invaded  lymphatics.  Thus  arises  the  appearance  of 
separate  metastases,  whereas  in  reality  such  secondary  deposits  are  or  have 
been  (before  the  intervening  cell  strands  were  destroyed)  in  microscopic 
continuity  with  the  original  growth. 

Secondary  deposits  occur  more  readily  in  some  tissues  than  in  others, 
and  this  selective  action  varies  with  the  sort  of  growth.  Thus  prostatic 
cancer  is  particularly  liable  to  be  followed  by  secondary  deposits  in  the 
bones. 

Leuzinger  noted  that  metastases  occur  in  bone,  in  3  per  cent,  of  cases 
with  uterine  cancer,  in  14  per  cent,  of  cases  with  cancer  of  the  breast,  while 
with  cancer  of  the  thyroid  the  bones  were  affected  in  no  less  than  20  per  cent, 
of  the  cases. 


TERATOMAS  77 

Further,  it  has  been  noted  that  in  early  stages  of  cancer  of  the  breast 
cancerous  emboli  reach  the  lung  but  are  unable  to  develop  there,  being 
destroyed  by  the  plastic  formation  of  scar-tissue  in  the  intima  of  the  blood- 
vessels. Metastatic  deposits  may  remain  clinically  latent  for  months  or 
years,  thus  explaining  the  difficulty  of  our  being  certain  of  cure  in  these 
cases  after  operation. 

Nutrition  of  Tumours.  This  depends  on  the  blood-vessels  which  pass 
in  the  stroma  between  the  cells  of  the  growth.  Formation  of  blood-vessels 
does  take  place  in  new  growths,  but  in  the  atypical  or  malignant  forms  these 
never  pass  beyond  the  stage  of  capillaries,  which  are  usually  ill-formed  and 
readily  give  way.  For  this  reason  haemorrhages  into  new  growths  are 
common  as  well  as  degenerations  of  various  sorts.  Neoplasms  are  devoid 
of  nerves.  We  have  already  called  attention  to  the  abnormalities  in  the 
nuclear  division  of  atypical  tumours,  pointing  out  that  the  chromosomes 
may  be  reduced  or  increased  in  numbers  for  the  particular  species  of  animal 
involved,  or  the  division  may  be  asymmetrical.  Such  alterations  at  present 
afford  food  for  speculation. 

SPECIAL  VARIETIES   OF  TUMOURS 

(1 )  Teratomas.  These  are  tumours  originating  from  totipotent  cells,  and 
may  contain  structures  derived  from  any  or  all  of  the  primary  germ-layers. 

A.  Ovarian  dermoids  (teratomas)  are  apparently  due  to  an  attempt  on  the 
part  of  an  ovum  to  undertake  parthenogenesis,  though  other  possibilities 
exist  to  explain  the  condition.  These  tumours  grow  from  the  ovary  in 
two  forms  : 

(a)  The  usual  type  is  a  cyst  lined  with  squamous  epithelium  containing 
sebaceous  and  sudiparous  glands  and  bearing  hairs.  The  contents  are 
yellowish  mortar-like  material,  the  produce  of  epithelial  desquamation  and 
the  secretion  of  the  cutaneous  glands  ;  in  addition  there  will  often  be  present 
plates  of  bone  and  teeth,  while  section  reveals  nervous  and  hypoblastic 
structures.  Clinically  these  tumours  are  seldom  detected  before  adult  life, 
when  they  will  be  found  as  ovarian  cysts,  very  often  becoming  twisted  or 
inflamed . 

(b)  Much  more  rare  are  sporadic  embryomas,  which  are  solid  and  contain 
more  definite  parts  of  an  embryo. 

B.  Testicular  teratomas  are  solid  or  made  up  of  small  cysts  and  are  usually 
highly  malignant.  Their  origin  is  only  detected  by  the  study  of  sections 
from  various  parts,  when  cells  of  nervous,  epithelial,  cartilaginous,  and 
glandular  origin  may  be  detected.  The  general  view  at  present  is  that  most 
testicular  tumours  originate  as  teratomas. 

C.  Foetal  inclusions.  These  would  appear  to  be  an  effort  on  the  part  of 
the  original  blastoderm  to  form  twins,  one  of  which  is  rudimentary  and  is 
implanted  somewhere  in  the  otherwise  normal  individual.  Never  very 
common,  the  best-known  position  is  over  the  sacrum  or  coccyx,  where  the 
tumour  is  known  as  the  sacro-coccygeal  teratoma  and  is  present  at  birth, 
forming  a  swelling  of  variable  size  over  the  sacro-coccygeal  region,  and  on 


78  A    TEXTBOOK  OF  SURGERY 

dissection  different  parts  and  organs  of  another  foetus  are  discovered.  These 
last  tumours,  then,  represent  the  brother  or  sister  of  the  patient  who  bears 
the  tumour  on  his  back,  while  the  ovarian  and  testicular  dermoids  represent 
the  ill-conditioned  descendants  of  the  patient. 

(2)  Mixed  Tumours  or  Teratoblastomas.  These  are  derived  from 
pluripotent  colls  and  contain  varieties  of  tissue  which  may  be  derived  from 
one  or  two  primitive  layers  of  the  embryo  but  not  all  three,  as  in  the  case 
of  teratomas. 

They  occur  in  the  kidney  and  salivary  glands  but  are  not  common  in 
either  situation. 

A.  Renal  mixed  tumours  (teratoblastomas).  These  are  found  in  infants 
and  young  children,  where  they  form  the  large,  rapidly  growing  tumours 


Fig.  15.     Mixed  tumour  of  the  parotid  (magnified),  also  described  as 
endothelioma. 


often  called  sarcomas.  In  structure  they  contain  renal  epithelium,  carti- 
lage cells,  plain  and  striated  muscle-fibres,  combined  with  a  sarcoma-like 
matrix  of  spindle  cells.  These  tumours  are  essentially  atypical  and  malig- 
nant in  nature. 

B.  Salivary  teratoblastomas,  mixed  tumours,  or  endotheliomas.  These 
occur  usually  in  the  parotid,  less  often  in  the  submaxillary  gland,  and  are 
sIow-lhow  ingj  encapsuled  in  type,  but  after  years  of  innocence  may  take  on 
an  atypical,  rapid,  infiltrating  growth,  becoming  highly  malignant.  They 
consist  of  columnar  and  squamous  epithelial  cells,  fibrous  tissues,  cartilage, 
and  even  bone,  in  a  stroma  of  connective  tissue.  Similar  tumours  are  found 
rarely  in  the  lacrymal  gland,  gums,  cheeks,  and  vagina.  Hyaline  degenera- 
tion, leading  to  the  formation  of  cylindrical  masses  of  homogeneous  material, 
has  given  rise  to  the  name  "  cylindroma,"  which  is  sometimes  applied  to 
these  tumours  as  well  as  to  endotheliomas,  in  which  similar  degenerations 


BLAST  OM  AS  79 

are  found.  (Note.  Some  authorities  class  these  tumours  with  endo- 
theliomas.)    (Fig.  15). 

C.  Odontomas,  or  tumours  connected  with  improper  development  of  the 
teeth,  should  be  placed  here,  since  they  contain  in  their  structure  parts 
formed  from  at  least  two  germ-layers,  viz.  the  epiblastic  enamel  organ  and 
the  fibrous  tissue  forming  the  tooth  follicle  ;  they  are  discussed  under 
Tumours  of  Bone. 

(3)  The  Blastomas  or  Tumours  derived  from  Unipotent  Cells.  In 
this  group  are  placed  most  of  the  ordinary  new  growths,  which,  arising  from 
cells  of  the  host  (patient),  are  called  autochthonous,  in  contradistinction  to 
heterochthonous  tumours,  which  originate  in  the  cells  of  a  different  indi- 
vidual, and  to  which  brief  notice  must  be  directed. 

(a)  Heterochthonous  or  teratogenous  blastomas.  The  developing  ovum 
fastens  itself  to  the  maternal  tissue  of  the  uterus  by  growths  of  cells  of 
the  chorion  (a  fcetal,  cellular  membrane  surrounding  the  embryo),  these 
outgrowths  being  called  chorionic  villi.  Chorionic  villi  invade  the  maternal 
tissues  very  much  as  do  the  infiltrating  cells  of  a  new  growth  the  tissues  of 
the  host.  But  there  is  a  limit  to  the  power  of  infiltration  of  the  chorionic 
villi,  which  normally  prevents  the  spread  of  the  cells  of  which  they  are 
composed.  Changes  may,  however,  occur  in  the  cells  of  the  villi  and  the 
process  of  invasion  go  beyond  the  bounds  of  physiological  growth.  This  is 
more  often  the  case  where  a  degeneration  of  the  chorionic  villi  has  taken 
place  with  formation  of  vesicles  in  the  villi  (known  as  a  hydatidiform  mole). 
In  a  certain  number  of  such  cases,  after  the  mole  is  extruded  from  the  uterus 
some  of  the  cells  of  the  invading  (syncytial)  layer  of  the  villi  continue  to 
grow  into  the  uterine  tissue  and  are  definitely  malignant  in  their  properties, 
spreading  rapidly  through  the  uterine  walls  and  causing  metastases  by 
entering  the  blood-  and  lymph-vessels.  This  form  of  new  growth  is  called 
chorio- epithelioma  and  spreads  rapidly,  invading  vessels  and  causing  profuse 
haemorrhages.  Xodules  are  often  found  in  the  vagina  even  when  none  can 
be  felt  in  the  uterus  or  even  when  the  condition  has  undergone  spontaneous 
cure  in  the  latter  situation,  for  these  invading  calls  are  readily  destroyed  by 
the  tissues  ;  still,  they  spread  so  rapidly  that  the  result  is  usually  fatal  from 
hemorrhage  somewhere  or  other.  For  further  information  works  on 
gynaecology  should  be  consulted. 

(b)  Autochthonous  blastomas : 

A— PURE  LEPIDOMAS 
Taking  first  the  lepidomas,  or,  as  they  may  in  general  be  termed,  the 
epithelial  tumours,  in  the  first  group  are  the  pure  lepidomas,  whether 
derived  from  epi-,  hypo-,  or  mesoblast.  These  have  practically  no  tendency 
to  undergo  hylic  changes  and  may  be  typical  or  innocent,  including  adenomas 
and  papillomas,  or  atypical  and  malignant,  consisting  of  invading  growths 
or  cancers  of  various  sorts. 

A.  Papillomas.  These  may  be  defined  as  outgrowths  from  the  surface 
or  from  the  walls  of  hollow  cavities,  which  are  covered  with  epithelium 
(squamous,  cubical,  or  columnar),  the  epithelial  cells  being  based  on  a  core 


80 


A  TF.  XT  BOOK  OF  SFRtiKUY 


of  connective  tissue  containing  blood  and  lymphatic  vessels.  Of  these 
there  are  several  varieties:  (1)  warts,  corns,  and  condylomas;  (2)  soft 
papillomas:   (3)  intracystic papillomas. 

(1)  Waits,  which  may  be  termed  "  irritation  papillomas,"  arc  out- 
growths of  the  papillae  of  the  corium,  with  increase  in  the  layers  of  epithelium 
covering  these  papillae.  It  is  questioned  by  some  authorities  as  to  whether 
warts  should  be  included  amongst  neoplasms  or  with  the  late  results  of 
inflammation,  being  then  called  "  blastomatoid  "  formations,  since  in  a  large 
number  of  cases  irritation,  infection,  and  inflammation  are  definitely  the 
causes  of  such  outgrowths.  Since,  however,  aquamous-celled  cancer  is 
regarded  by  all  as  a  new  growth,  and  this  is  often  due  to  the  further  develop- 
ment of  a  wart,  it  seems  only  reasonable  to  regard  warts  as  growths,  the 


^m>  '■■■ 


Fig.  16.     Warty  or  leucoplakial  growth  of  the  tongue.     Irregular  hypertrophy  of 
papillae  and  overgrowth  of  epithelium,  of  which  parts  are  excessively  keratinized 

(a,  a'). 

cause  of  which  is  actually  known  ;  this  shows  the  close  relation  of  some 
tumours  to  inflammations,  since  both  are  the  results  of  various  forms  of 
irritation.  It  is  no  reason  to  deny  these  simple  tumours  their  place  in  the 
hierarchy  of  new  growths  merely  because  we  happen  to  understand  their 
underlying  cause.  The  point  of  origin  of  papillomas  seems  to  be  the  epithe- 
lium, which,  so  to  speak,  leads  the  way,  becoming  proliferated  and  causing 
the  underlying  connective  tissue  to  grow  out  and  form  projections  clot  lied 
with  the  hypertrophic  epithelium.  Waits  vary  in  appearance  according 
♦  ii  their  position.     (Fig.  16.) 

('/)  On  exposed  surfaces  they  are  pointed  and  hard,  covered  with  much 
indurated  epithelium.  In  some  cases  the  epithelium  becomes  so  much  piled 
up  that  an  actual  horn  is  formed  (cutaneous  horn),  (b)  Where  they  occur 
in  moist  situations,  e.g.  along  the  corona  glandis.  associated  with  balanitis 
gonorrhoea,  ike.  the  epithelial  covering  is  not  increased  so  much  and  the 
wnits  are  soft,  (c)  In  other  places  where  there  is  pressure  in  addi- 
tion to  irritation,  the  epithelium  is  condensed  and  flattened  around  the 
core    of    hypertrophied  papillae   so    as   to   form   a   large   callosity.     Such 


PAPILLOMAS 


81 


flattened  and  condensed  warts  are  known  as  "  corns,"  which  consist  of 
papillomas  with  an  excessive  amount  of  compressed,  non-desquamating 
epithelium  on  the  surface.  The  "  leucoplakia "  of  the  mouth  and 
tongue  are  allied  conditions  (see  Diseases  of  the  Tongue  and  Mouth). 
(d)  Condylomas.  These  are  papillomatous  outgrowths  found  in  moist 
surfaces  of  the  body — e.g.  the  natal  cleft,  vulva,  &c. — and  consist  of  hyper- 
trophied  masses  of  connective  tissue  covered  with  loose  sodden  epithelium, 
and  are  the  result  of  long  continuance  of  the  "  mucous  patches  "  of  secondary 
syphilis.  Pathologic- 
ally they  are  very 
much  akin  to  the  soft 
warts  already  men- 
tioned, both  being  due 
to  the  irritation  of 
chronic  discharges. 
Similar  polypoid  con- 
ditions are  found  in 
the  stomach,  colon, 
larynx,  &c,  as  the  re- 
sult of  chronic  inflam- 
mation. 

(2)  Soft  papillomas 
of  unknown  origin  aris- 
ing quite  apart  from 
inflammation.  The  best 
known  of  these  are  the 
villous  tumours  of  the 
bladder,  consisting  of 
long  outgrowths  of  fea- 
thery papilla?  covered 
with  a  few  layers  of 
transitional  bladder 
epithelium  ;  these  tu- 
mours bleed  readily,  and  if  persisting  long  are  liable  to  undergo  malignant 
changes.     (Fig.  17.) 

(3)  Intracystic  papillomas.  These  occur  most  commonly  growing  from 
the  walls  of  ovarian,  mammary,  and  thyroid  cystic  adenomas,  and  their 
structure  is  similar  to  other  papillomas,  viz.  a  basis  of  connective-tissue 
bearing  epithelium. 

B.  Adenomas.  These  are  formed  of  gland  cells,  such  as  those  of  the 
mamma,  thyroid  gland,  ovary,  liver,  cutaneous  glands,  &c. 

In  structure  they  closely  resemble  the  normal  gland,  from  which  they 
originate,  in  the  arrangement  of  the  cells  in  alveoli,  and  in  forming  to  some 
degree  the  normal  secretion,  whether  mucous,  thyroid-colloid,  bile,  &c%  ; 
but,  being  without  ducts,  the  secretion  tends  to  collect  and  form  cystic 
spaces.     The  gland  cells  are  the  dominant  feature  in  most  cases,  the  stroma 


S: 


Fig.  17.     Suction  of  a  papilloma  of  the  bladder  (magnified). 


82 


A  TEXTBOOK  OF  STROKRY 


playing  n  secondary  part.  There  are.  however,  exceptions  to  this 
e.g.  in  fibro-adenomas  of  the  breast  the  stroma  is  often  of  Ear  greater 
amount  than  the  glandular  elements  :  moreover,  should  malignanl  changes 
take  place  in  fibro-adenoma  of  the  breast  it  is  more  likely  to  occur  in  the 
Btroma  than  in  the  gland  cells.  In  most  instances  of  adenoma,  however,  it 
is  the  glandular  cells  of  an  adenoma  which  undergo  malignanl  changes  and 
form  cancers.     Adenomas  are  usually  in  the  substance  of  the  gland  from 

which  they  originate,  but  may 
be  separated  and  even  peduncu- 
lated, as  are  adenomas  of  the 
intestine  or  rectum. 

C.  Atypical  lepidomas,  cancer, 
malignant  epithelial  tumours,  car- 
cinoma. These  terms  are  applied 
not  only  to  atypical 
pure  lepidomas,  but 
in  addition  to  any 
atypical  tumour  of 
epithelial  nature, 
such     as     malignant 

MdM>'i!fs&**^fc%^^n     VJ     mixed  tllmours  of 

testis  and  kidney ; 
some  of  the  latter  are  also  de- 
scribed as  sarcomata.  In  cancers 
there  is  a  greater  lack  of  differ- 
entiation of  the  principal  cells 
(anaplasia)  than  is  met  with  in 
adenomas  or  papillomas,  though 
this  departure  from  type  may  not 
be  very  great  in  extremely  malig- 
nant tumours. 

The  great  feature  in  cancerous 
tumours  is  that  the  epithelial  cells 
proliferate,  often  forming  many  layers,  and  escape  through  the  basement 
membrane  into  the  stroma  or  surrounding  connective  tissue,  which  is  in 
this  way  invaded.  The  invading  epithelial  (lepidic)  cells  pass  into  the 
surrounding  tissues  along  the  tissue-spaces  and  smaller  lymphatics.  In 
most  instances  this  invasion  of  the  tissues  leads  very  soon  to  metastases 
from  spread  along  the  larger  lymph  channels  by  embolism.  In 
some  instances,  however,  the  invasion  may  be  strictly  local,  as  is  the 
case  with  "rodent  ulcers"  which,  though  slowly  growing,  are  of  great 
malignancy  and  yet  never  give  rise  to  metastases.  The  local  inva- 
sion by  epithelial  cells  may  lead  to  a  well-marked  inflammatory  reaction  ; 
this  is  most  often  seen  where  there  has  been  inflammation  previously, 
as  noted  in  cancers  of  the  lip  or  tongue  originating  in  leucoplakia  or 
warts. 


Fig.  18.     Epithelioma  of  lip  (magnified).     Note 
the  downgrowth  of  atypical  cells  of   the  epithe- 
lium and  formation  of  cell-nests. 


CANCER  83 

Cancers  may  be  divided  according  to  the  type  of  cell  present.  The 
following  main  varieties  are  described  : 

(1)  Squamous-celled  cancer  or  epithelioma,  derived  from  stratified 
squamous-celled  epithelium  of  the  skin,  mucosa  of  the  mouth,  tongue,  anal 
canal,  &c. 

(2)  Spheroidal-celled  cancer,  in  which  the  cells  were  originally  cubical 
in  shape,  as  in  cancers  arising  in  the  glandular  tissue  of  the  breast  or  by 
alteration  of  the  columnar  cells  of  the  stomach. 

(3)  Columnar-celled  cancer,  where  the  cells  tend  to  preserve  their 
arrangement  in  alveoli,  as  in  cancer  of  the  large  intestine  and  rectum.  Such 
cancers  are  sometimes  called  malignant  adenoma  or  adenocarcinoma. 

Cancers  may  also  be  classified  according  to  the  reaction  between  invading 
cells  and  the  stroma,  as  follows  : 

( 1 )  Simple  cancer  is  the  term  applied  to  those  where  the  invading  epithe- 
lial cells  and  the  stroma  are  equally  developed,  neither  predominating. 

(2)  Medullary  or  encephaloid  cancer,  where  the  epithelial  elements  form 
the  greater  part  of  the  picture  ;  the  growth  is  very  rapid  and  soft,  soon 
forming  masses  resembling  brain  or  marrow7,  and  is  highly  malignant. 

(3)  Scirrhus  or  hard  cancer,  where  the  stroma  is  in  excess  and  the  epithe- 
lial elements  scanty,  the  tumour  tending  to  be  small,  slow-growing,  and  of 
low  malignancy.  Where  the  formation  of  stroma  is  very  greatly  in  excess 
relatively  to  the  growth  of  epithelial  cells,  the  term  "  atrophic  scirrhus  "  is 
applied.  Such  cases  may  be  regarded  as  examples  of  a  tolerably  successful 
reaction  of  the  tissues  against  the  invading  parasitic  cells.  Atrophic  scirrhus 
of  the  breast  is  the  best-known  example  of  this  type,  and  may  last  as  long 
as  ten  to  twenty  years  or  more  without  proving  fatal.  The  rare  instances 
in  which  cancer  heals  spontaneously  form  the  extreme  example  of  this 
type. 

(4)  In  rare  instances  the  stroma  as  well  as  the  epithelial  cells  takes  on 
atypical  development  and  the  tumour  becomes  a  mixture  of  sarcoma  with 
carcinoma,  or  "carcinoma  sarcomatoides." 

Further,  degenerations  readily  take  place  in  such  atypically  growing 
cells.  These  may  be  small  intracellular  bodies  or  yeast-like  forms,  which 
have  been  described  as  parasites  and  regarded  as  the  cause  of  cancer,  but 
there  is  no  reason  to  believe  that  these  are  anything  more  than  degenerated 
parts  of  cells.  Larger  degenerations  may  lead  to  the  condition  known  as 
colloid  cancer  or  the  formation  of  cysts  and  haemorrhages  in  the  substance 
of  cancers. 

(1)  Squamous-celled  Cancer,  Epithelioma,  Epidermal  Cancer. 
These  growths  originate  in  epithelium  of  squamous  nature,  whether  of  the 
epiblast  (as  the  skin  of  lip,  mucosa  of  the  tongue),  or  the  hypoblast  (as  the 
lining  mucosa  of  the  oesophagus),  or  of  mesothelial  mucosa  (as  that  of  the 
vagina  or  cervix  uteri).  Such  new  growths  may  also  arise  where  squamous 
cells  are  not  normally  present,  from  alteration  of  columnar  into  squamous 
epithelium  by  repeated  irritation,  as  in  the  larynx.     (Figs.  18  and  19.) 

Squamous-celled  cancer  is  usually  met  with  in  the  middle-aged  and 


84 


A  TEXTBOOK  OF  SURGERY 


elderly,  and  often  is  the  resull  of  irritation,  mechanical  or  chemical,  as  from 
clay-pipes  or  coal-tar  products.  The  formation  is  characterized  l>\  the 
downgrowth  of  columns  of  squamous  epithelial  cells  Into  the  underlying 
tissues,  causing  an  inflammatory  reaction  of  varying  degree.  The  cell- 
columns  consist  of  single  or  many  rows  of  cells,  in  the  latter  case  often 
forming  the  structures  known  as"  cell  nests  "  or"  epithelial  pearls."  These 
pearls  are  made  up  of  concentric  arrangements  of  epithelial  cells  resembling 


Fig.  19.     Squamous-cclled  cancer  of  the  tongue  (epithelioma)  (magnified).     Passing 

from  a  to  b,  the  epithelium  becomes  increased  in  thickness  and  columns  grow  down 

into  the  underlying  tissue  ;    below  da"  cell-nest "  is  seen. 


the  section  of  an  onion.     The  principal  cells  of  these  tumours  are  "  prickle  " 
cells  and  contain  keratin.     Clinically,  squamous-celled  cancer  is  found,  as  : 

(a)  Warts  with  dense,  indurated  base  (the  infiltration  being  that  of  the 
invading  cell-columns). 

(b)  Malignant  ulcers  which  have  a  hard,  everted  or  "  rolled  "  edge,  a 
callous  or  sloughy  floor  partially  covered  with  poor  granulations,  and  infil- 
trated base,  indolent  enlargement  of  the  appropriate  lymph-nodes  being 
common. 

(c)  Hypertrophic  or  cauliflower  growths.  The  overgrowth  and  neo- 
plastic formation  is  largely  superficial,  so  that  the  surface  of  these  growths 
resembles  hypertrophic  granulation  tissue  ;  the  base  is  relatively  slightly 
infiltrated  ;   neighbouring  glands  may  be  noted  as  being  hard  and  enlarged. 


CANCER 


85 


o 


Oi 


■mxi 


00o  '/ 


m 


fe>  ° 


■o 


* 
»o :  o  ■ 

M 


(d)  In  some  cases  a  solid  plaque  is  formed  with  little  overlying  ulceration 
of  the  surface  epithelium  ;  this  form  is  found  in  the  tongue  but  is  not 
common.  The  "  rodent  ulcer  "  seems  to  be  more  appropriately  placed  with 
the  spheroidal-celled  cancers,  though  appearing  on  the  skin. 

Infection  of  lymphatics  from  these  growths  occurs  at  varying  periods. 
Thus,  in  the  case  of  the  tongue  the  glands  are  infected  early,  i.e.  in  a  few 
months  or  even  weeks,  whereas  in  the  case 
of  the  lip  or  the  interior  of  the  larynx  glan- 
dular infection  may  not  occur  till  very  late 
in  the  affection,  which  remains  chiefly  local. 
On  the  other  hand,  in  certain  places,  e.g.  the 
aryteno-epiglottic  folds,  if  the  seat  of  cancer, 
may  give  rise  to  enormous  secondary  glan- 
dular enlargement  while  the  primary  growth 
is  quite  small  and  perhaps  not  easy  to  find. 
Obvious  malignant  glands  of  the  neck  in 
which  no  primary  is  found  often  turn  out  to 
be  of  this  nature. 

(2)  Spheroidal-celled  Cancer.  This 
condition  arises  chiefly  in  secreting  glands 
whose  cells  may  be  cubical,  spheroidal,  or 
columnar,  such  as  the  breast,  stomach,  thy- 
roid, prostate.  The  epithelium  penetrates 
the  basement  membrane  and  invades  the 
surrounding  tissues  or  stroma,  the  relative 
amount  of  the  latter  giving  rise  to  the 
various  types  of  cancer — simple,  scirrhus, 
and  medullary — already  described.  The 
cells  show  little  tendency  to  maintain  their 
alveolar  arrangement,  but  this  may  be  in- 
dicated to  some  degree,  when  the  term 
adeno-carcinoma  is  used.     (Fig.  20.) 

The  principal  cells  are  of  very  diverse 
shapes  and  metastases  in  the  lymphatic 
glands  are  common.  Clinically  spheroidal- 
celled  cancers  are  found  as  : 

(a)  A  hard  mass  of  growth  or  tumour  in  the  simplest  sense,  spreading 
through  the  tissues,  having  no  very  distinct  outline  and  becoming  rapidly 
adherent  to  surrounding  structures.  When  the  skin  becomes  involved, 
necrosis  and  ulceration  of  the  growth  lead  to  the  formation  of  an  ulcer 
which  is  fungating  or  callous,  according  as  the  growth  is  more  or  less  exube- 
rant. Encephaloid  cancer  leads  to  fungating  ulcers,  while  scirrhous  cancer 
tends  to  produce  ulcers  not  unlike  the  callous  ulcer  of  chronic  infection  and 
malnutrition.     Necrosis,  colloid  degeneration,  &c,  often  occur. 

(b)  Rodent  ulcer.  This  is  an  invading  ulcerating  growth  of  the  skin 
formed  of  branching  columns  of  cells  devoid  of  prickles  and  keratin,  slowly 


.?■       <*\ 

•'■'-V:    -.   ■' 


r. 


Fig.  20.  Carcinoma  of  the  pylorus 
(magnified).  In  the  upper  part  of 
the  figure  normal  columnar  epi- 
thelium will  be  noted,  while  lower 
down  the  invading  islands  of 
darker  staining  and  altered  cells 
are  found  in  the  submucous  and 
muscular  layers. 


A  TEXTHooK   OK SlKCKKV 


advancing  into  the  neighbouring  tissues.  The  cells  <»l  the  growth  are 
smaller  than  those  <>t  squamous-celled  cancer,  stain  more  deeply,  ami  never 
form  cell-nests  nor  metastatic  deposits  in  glands.  Although  advance  is 
.-low.  the  ulcer  not  being  larger  than  a  five-shilling  piece  after  as  many  years 
and  sometimes  healing  temporarily  at  some  point  of  the  periphery,  yet 
malignancy  is  very  great  and  recurrence  alter  removal  frequent.  The 
origin  of  these  growths  is  uncertain,  some  holding  that  they  originate  in 
the  Malpighian  layer  of  the  skin,  but  the  absence  of  prickles  ami  keratin  is 
against  this  view.     It  is  more  probable  that  they  commence  in  some  (»l 


the  skin-glands,  sebaceous  or  sweat,  or  possibly  in  hair  follicles  ;  and  it 
may  be  noted  that  their  seat  of  election  is  where  glands  are  very  numerous, 
i.e.  on  the  face  above  the  mouth,  especially  at  the  angles  of  the  eye  and 
the  attachment  of  the  ear  and  nose.     (Fig.  22.) 

(3)  Columnar-celled  Cancer.  This  always  originates  in  columnar 
epithelium,  e.g.  that  of  the  intestine  or  stomach.  The  invading  cells  main- 
tain some  attempt  at  an  alveolar  arrangement,  but  this  is  never  very 
complete,  and  the  cells  are  atypical  in  shape  and  staining  reactions.  The 
malignancy  of  these  growths  is  considerable  in  spite  of  the  fact  that  they 
are  allied  in  structure  to  the  adenomas.  Like  other  forms  of  cancer,  there 
is  a  variable  relation  between  the  principal  cells  and  the  stroma,  and  there 
may  be  slowly  growing  scirrhus  tumours  or  rapidly  spreading  encephaloid — 


RODENT   ULCER 


87 


the  former  tending  to  produce  stenosis  of  the  hollow  viscera  in  which  they 
start  (as  pyloric  or  intestinal  stenosis  and  obstruction),  the  latter  forming 
f ungating  masses  on  the  internal  surface  of  the  organ  affected.      (Fig.  23.) 


B— TRANSITIONAL  LEPIDOMAS 

These  tumours  are  derived  from  the  mesothelium,  and  include  tumours  of 
the  ovary,  testis,  kidney,  and  those  derived  from  the  serous  linings  of  body 


Fig.  22.     Rodent  ulcer.     The  smaller,  darkly  staining  cells  of  the  columns  (b)  in 
the  new  growth  are  quite  distinct  from  the  normal  squamous  epithelium  («). 

cavities  and  spaces,  as  the  peritoneum,  lymphatics,  &c.  It  should  be  noted 
that  in  a  large  number  of  instances  the  tumours  of  this  origin  are  pure 
lepidomas,  having  no  tendency  to  take  on  hylic  (sarcomatous  growth),  as, 
for  example,  the  common  cystic-adenomas  of  the  ovary,  adenomas  of  the 
prostate,  cancer  of  the  uterus,  &c.  So  long  as  these  growths  are  typical 
they  show  little  tendency  to  assume  the  transitional  form  ;  it  is  only  when 
they  are  structurally  atypical  and  clinically  invading  that  the  stroma  takes 
on  atypical  growth.  The  transitional  type  is  chiefly  found  in  the  kidney, 
since   most    ovarian  tumours  are  purely  epithelial  (lepidic)   and   those   of 


A  TEXTBOOK  OF  SURGERY 

the  testicle  are  now  generally  regarded  as  teratomas  with  malignant  pro- 
pensities. 

(1)  Mesotheliomas,  (a)  The  transitional  tumours  found  in  the  kidney 
are  known  as  hypernephromas,  "Grawitz  tumours,"  or — perhaps  better — 
as  renal  mesotheliomas,  since  the  most  generally  accepted  view  is  that 
these  growths  are  not  derived  from  adrenal  rests  but  from  the  renal 
epithelium. 

The  structure  of  these  tumours  presents  a  considerable  resemblance  at 
tirst  sight  to  suprarenal  tissue,  since  their  cells  are  large  and  vacuolated 


Fig.  23.     Columnar-celled  cancer  of  the  colon  (magnified).     The  smaller,   more 

darkly  staining  cells  of  the  cancerous  part  (a)  contra -t  with   the   Larger  mucous 

cells  (b)  of  the  normal  gut,  though  the  former  maintain  their  general  shape  and 

alveolar  arrangement. 

and  arranged  in  columns  and  strands  somewhat  after  the  fashion  of  that 
which  obtains  in  the  suprarenal  gland. 

Distinct  tubules  are,  however,  found  in  places,  and  these  tumours  do 
not  commence  under  the  capsule  of  the  kidney,  as  is  the  case  with  definite 
adrenal  rests,  and  are  more  common  at  the  lower  pole,  while  the  position 
of  the  suprarenal  is  at  the  upper  pole.  The  growths  may  be  typical,  i.e. 
adenomas,  but  more  often  are  invading  and  atypical  in  structure.  One 
notable  feature  about  such  tumours  is  that  with  increase  in  size  the  stroma, 
as  well  as  the  principal  cells,  tends  to  become  atypical  or  to  assume  sarco- 
matous form. 

(b)  Mesotheliomas  of  serous  surfaces,  tending  to  assume  atypical  features 
and  be  malignant,  are  often  described  as  endotheliomas,  which  in  view  of 
their  origin  is  not  a  bad  name.  They  consist  of  columns  of  cells  arranged 
in  alveoli  or  strands.     The  stroma  is  distinctly  atypical  and  resembles 


NiEVI 


89 


sarcomatous  tissue  ;  in  spite  of  this  the  tumours  are  usually  of  slow  growth, 
slight  invading  powers,  and  metastases  are  uncommon. 

(2)  Endotheliomas  (in  the  wide  sense,  i.e.  lepidic  tumours  derived  from 
lining  endothelium).  In  the  first  place,  it  must  be  observed  that  the  term 
endothelioma  is  used  loosely  to  include  a  number  of  tumours  of  varying 
origin,  including  the  mixed  tumours  of  the  parotid,  mesotheliomas  of  serous 
surfaces,  as  well  as  those  derived  from  the  lining  of  the  blood-  and  lymph- 
vessels,  while  simple  tumours  arising  from  these  vessels  are  often  classed 
with  the  connective -tissue  tumours.  We  follow  Adami  in  this  classification 
and  regard  the  angeiomas  of  lymphatic  and  vascular  origin  as  typical 


M 


m  mmmmmmM 

Fig.  24.     Cutaneous  nsevus  or  birth-mark  (magnified).     The  dilated  capillaries  and 
cavernous  spaces  filled  with  blood  are  obvious. 


endotheliomas,  the  atypical  varieties  as  forming  part  of  the  group  usually 
known  as  endotheliomas. 

(a)  TYPICAL  ANGEIOMAS 

As  Adami  points  out,  a  large  number  of  vascular  and  lymphatic  tumours 
are  not  blastomas  or  new  growths  at  all,  either  because  (1)  they  are  the 
result  of  inflammation  or  trauma,  as  is  the  case  with  ordinary  aneurysms ; 
or  (2)  they  are  the  result  of  pressure  and  consequent  dilatation,  as  in 
hemorrhoids  and  other  varicose  conditions  of  veins  ;  or  (3)  because  they 
do  not  grow  (persistent  growth  being  part  of  the  definition  of  a  blastoma  or 
neoplasm).  This  last  is  the  case  with  many  naevi  or  capillary  ha?mangeiomas. 
Such  cases  are  more  accurately  described  as  congenital  anomalies  rather 
than  as  new  growths.  Custom,  however,  and  the  fact  that  some  of  these 
formations  show  considerable  power  of  growth  makes  us  include  nsevi  under 
this  heading. 

(1)  Typical  H^mangeiomas.  These  will  be  described  in  more  detail 
in  the  section  on  Vascular  Surgery  ;  suffice  it  here  to  mention  that  they 
occur  in  three  main  groups  : 

(a)  The  capillary  nsevus,  port- wine  stain  or  birth  mark,  which  consists  of 


A    rEXTBOOK   OF  Sl'R(JKRY 


masses  of  capillaries  closely  congregated  together  and  increased  both  in 
size  and  numbers. 

(b)  The  cavernous  nawus.  In  these  cases  aumbers  of  capillaries  and 
perhaps  small  veins  are  dilated  into  cavernous  spaces  forming  marked 
projections  on  the  sin  lace.     (Fig.  24.) 

(c)  Arterial  angeiomas  or  cirsoid  aneurysms.  Here  there  is  excessive 
growth  and  new  formation  of  arteries,  forming  a  spreading,  plexiform, 
pulsating  tumour.      It   should   be   noted   that    capillary  and   cavernous 

angeiomata  may  remain  stationary 
or  grow  slowly  up  to  a  certain 
point  in  early  life,  and  this  often 
renders  complete  cure  by  excision 
not  easy  unless  a  tolerably  wide 
operation  is  done.  The  cirsoid 
aneurysm  grows  indefinitely  and 
may  almost  be  said  to  have  a 
local  malignancy,  so  difficult  is  it 
to  cure  with  certainty  by  removal. 
(2)  Typical  Lymphangeiomas. 
sometimes  known  as  lymphangeiec- 
tases. 

(a)  Capillary.  These  occur  on 
the  surface  of  the  skin,  resembling 
capillary  naevi  of  blood-vessels,  but 
instead  of  being  red  or  purple  are 
yellowish  in  colour.  Not  infre- 
quently lymph  is  discharged  from 
their  surfaces  (lymphorrheea). 

(b)  Cavernous  lymphatic  ngevi, 
where  the  capillaries  are  dilated 
into  spaces,  as  exampled  in  machro- 
cheilia  (thick  lip),  macroglossia 
(large  tongue),  both  of  which  are 
congenital  conditions  or  arising 
from  blocking  of  lymph-vessels. 

(c)  Cystic  hygromas  or  cystic 
lymphangeiectases.  These  are  dilatations  of  lymphatic  vessels  cut  off 
from  the  general  lymph-circulation  and  so  forming  cysts,  and  most  usually 
occur  in  the  neck  or  axilla. 


Fig.  25. 


Section  'if  a  pigmented  mole 
(magnified). 


(b)  ATYPICAL   ENDOTHELIOMAS 

These  tumours  are  formed  of  columns  of  cells  arising  from  the  endothe- 
lium of  blood  or  lymph  channels,  so  that  the  endothelium  around  the 
capillaries  is  several  layers  thick  and  arranged  in  a  radial  manner  or  in 
whorls  ;  between  these  columns  or  whorls  is  a  loose  stroma.  These  growl  lis 
are  sometimes  known  as  peritheliomas  from  the  arrangement  of  cells  around 


MELANOMA  91 

capillaries,  and,  though  atypical,  are  in  many  instances  of  low  malignancy 
(e.g.  skin-moles,  which  belong  to  this  group,"  are  as  a  rule  quite  innocent) 
and  slow  growth.  In  some  instances  considerable  malignancy  is 
evinced,  as  in  the  case  of  alveolar  sarcomas,  which  appear  to  belong  to  this 
group. 

(c)  MELANOMAS 

The  correct  classification  of  these  tumours,  which  are  sometimes  called 
Melanotic  Sarcomas  or  Melanotic  Carcinomas,  is  not  easy  to  settle,  since 
they  consist  of  a  spindle-celled  stroma  of  sarcomatous  appearance,  amongst 
which  are  pigmented   cells   ap- 
parently  of   lepidic    (epithelial)     ^fcif   /. -  fP%.'0      '  -■ 
nature.      These  pigmented  cells     /  -  it  0J"  /,  Ij'M'i.  ||  %&% 


nature,      inese  pigmented  ceus      m,  .-     W  ~  /    r  p ^  y  ft^^f 

in  some  instances  show  a  very      'ft    '  o  f.'f".!  '"Ji*  .  °0    wZp'^tfi  3 

definite    epithelial    or    alveolar     mifc*/9ty$'jfP 

arrangement,     in      others      are       :    ^^§{     j        //.*  -J 

•  * ft  i 


0       9V 


sting  \^*^!^  #  M 

with  #v^\woW      W 

,le  of       *   ♦•  %    N\\'4*  N  V    JIM     V' 


scattered   through   the   spindle-      dj.l      J     ''* '■■''' j'r^\^  J  Jmi 

celled    stroma ;    moreover,    the     f      \\    '  .'    )  *?     .,••  •    '  •* 

secondary  deposits  may  be  quite      *«&'  |  n       %&§'*■■&    ?i 

devoid    of    pigment    cells.      It     K^^a         ';  i     Wm 

seems  best  to  regard  them  as  a 

combination  of  carcinoma  with 

sarcoma,    or,    in    other    words, 

both  principal  cells  and  stroma      j$  |»  0     '%\.!i§  J    £*T*»    '     ''//■/< 

are  equally  atypical,  active,  and 

malignant.     (Fig.  26.)  ^H 

These    growths    are    highly 
malignant,  and  it  is  interesting 
to    note    their    connexion 
the  common  pigmented  mole  of 

the  skin  from  which  they  some-      fc%t£i'&  *n%     '  A  %ltf  '       ' 
times   take   origin.      Such   moles     Fig.  26     Section  of  a  melanotic  growth  (magnified), 
consist     of    a    fibrous     stroma 

containing  clumps  of  pigmented  cells  surrounding  the  blood-  or  lymph- 
vessels,  in  some  instances  a  nsevoid  condition  being  present  as  well. 
(Fig.  25.) 

Although  macroscopically  well  defined  from  the  surrounding  skin,  under 
the  microscope  the  stroma  of  these  clinically  innocent  moles  ends  vaguely 
in  the  surrounding  tissues,  suggesting  an  infiltrating  growth. 

The  general  view  at  present  is  that  the  pigmented  part  of  the  melanoma 
is  derived  from  the  deeper  layers  of  the  epidermis  (which  also  contains 
pigment).  The  pigmented  cells  are  of  varying  shape — spheroidal,  spindle- 
shaped,  &c. — and  are  arranged  in  varying  manner  through  the  stroma. 
Metastases  in  the  liver  and  glands  are  common.  Clinically  they  occur  in 
the  choroid  of  the  eye,  in  pigmented  moles,  and  in  the  finger-pulp  around 
the  nail  as  black  tumours  infiltrating  their  surroundings,  and  are  likely  to 


92  A  TEXTBOOK  OF  SURGERY 

prove  fatal  from  internal  metastases  within  three  years;    but  their  eourse 
is  extremely  variable,     metastases  may  remain  latent  for  as  much  as  ten 

years  after  removal  of  the  primary  tumour,  hut  they  almost  invariably  recur 
sooner  or  later  in  spite  of  early  ami  thorough  removal. 

C.  HYLOMAS,  i.e.  TUMOURS  DERIVED  FROM  HYLIC  TISSUES 
As  in  the  ease  of  epithelial  tumours,  so  hylic  growths  may  be  divided 
into  typical  (or  those  formed  of  fully  formed  adult  tissues)  and  atypical  (or 
those  formed  of  imperfectly  developed,  embryonic,  rapidly  growing,  or 
vegetative  cells).  The  latter  group  are  known  by  the  general  name  of 
Sarcoma  and  are  malignant. 

I.  TYPICAL    HYLIC  TUMOURS 

(a)  Hvlomas  Derived  from  the  Epiblast.  (1)  True  Neuroma. 
These  have  been  very  rarely  described  arising  from  the  sympathetic  ganglia. 
They  are  of  large  size  and  made  up  of  ganglion  cells,  foiming  large  retro- 
peritoneal abdominal  tumours. 

"  False  Neuroma  "  in  which  there  is  no  new  formation  of  nerve  cells,  but 
only  increase  in  length  of  their  axis  cylinders,  and  overgrowth  of  surrounding 
connective  tissue,  wmether  following  injury,  as  amputation  neuromas  or 
localized  new  growths  as  fibroneuromas  or  generalized  as  neurofibromatosis 
(von  Recklinghausen's  disease)  is  described  under  the  affections  of 
peripheral  nerves. 

(2)  Glioma.  These  are  formed  of  the  stellate  cells  of  the  neuroglia  and 
their  branching  processes  and  occur  in  the  brain,  spinal  cord,  and  retina. 
In  the  brain  they  may  be  hard  or  soft,  the  former  being  encapsuled  and 
often  removable,  the  latter  being  ill-defined  and  merging  into  the  surround- 
ing nervous  tissues,  and  although  not  very  atypical  and  not  giving  rise  to 
metastases,  are  for  practical  purposes  to  be  regarded  as  locally  malignant. 
Gliomas  of  the  retina  are  always  malignant,  the  cellular  elements  being 
in  excess  compared  with  the  intercellular  fibrillse.  Hence,  they  are  often 
looked  upon  as  round-celled  sarcomas.  They  are,  in  fact,  gliosarcomas. 
and  infiltrate  locally  as  Well  as  give  rise  to  metastases. 

(6)  Hylomas  Derived  from  the  Hypoblast.  We  may  note  as  of 
pathological  interest  the  rare  Chordoma,  which  arises  in  the  remains  of  the 
i  iot  <  »chord  in  the  intervertebral  discs  and  which  may  assume  in  some  instances 
a  definite  sarcomatous  structure. 

(c)  Typical  Mesenchymatous  Hylomas  or  Connective-Tissue 
Tumours. 

i.   FIBROMA 

These  tumours  consist  of  white,  fibrous   connective  tissue  containing 

the  usual  branching  connective-tissue  cells.     The  cells  are  in  greater  number 

than  in  normal  tissue  and  of  less  mature  character  (presumably  if  quite 

mature  growth  would  cease).     According  to  the  arrangement  of  the  cells 


FIBROMA 


93 


and  fibrils  we  may  divide  fibromas  into  :  (a)  Hard  Fibroma  ;  (6)  Soft  Fibroma 
and  Fibromatosis,  and  (c)  Keloid. 

(a)  Hard  Fibromas.  These  consist  of  closely  interlacing  bundles  of 
connective-tissue  fibrils,  forming  rounded  masses,  hard  to  the  touch,  cutting 
with  a  creaking  sensation,  well  defined  and  as  a  rule  encapsuled.  In  some 
instances  after  years  of  slow,  innocent  growth  the  cell  elements  become  more 
abundant,  of  more  embryonic  type,  and  the  tumour  grows  rapidly,  becoming 
a  definite  sarcoma. 

Fibromas  occur  in  various  situations,  often  arising  from  deep  fascia, 
especially  of  the  abdominal  wall,  where  they  are  sometimes  known  as 
"  desmoids."  In  this  situation  the 
tendency  to  become  sarcomatous 
is  considerable.  In  connexion  with 
the  periosteum  of  the  jaws  and 
nasopharynx  fibrous  tumours  are 
found,  but  from  their  tendency  to 
recur  unless  widely  removed,  as 
well  as  from  their  structure,  they 
are  better  classed  with  spindle- 
celled  sarcomas.  It  must  be  noted, 
however,  that  slowly  growing 
spindle-celled  sarcomas  and  rapidly 
growing  fibrous  tumours  can  hardly 
be  separated,  clinically  or  micro- 
scopically, and  intervening  types 
certainly  occur.  Growing  in  the 
course  of  nerves  fibromas  are  called 
neuro-fibromas.  In  the  breast 
fibrous  tumours  are  frequent,  con- 
taining glandular  or  duct-epithelium 
in  varying  quantities.  Some  of 
these  seem  to  be  really  fibromas, 
which  have  included  in  their 
growth     some     epithelium,     while 

others  must  be  regarded  as  adenomas,  the  fibrous  tissue  being  merely  the 
stroma  of  the  tumour. 

(b)  Soft  Fibromas  and  Fibromatosis.  Soft  fibromas  are  made  of 
loosely  connected  bundles  of  fibrous  tissue  with  considerable  intervening 
spaces,  the  lymphatics  being  often  increased.  They  are  not  well  defined 
or  encapsuled,  and  it  is  often  questionable  whether  such  conditions  should 
be  regarded  as  new  growths  in  the  strict  sense.  Adami  labels  them  fibro- 
matoid,  and  points  out  their  connexion  to  progressive  hypertrophy,  e.g. 
hypertrophy  of  the  breast.  They  are  often  of  congenital  origin  and  consist 
of  overgrowth  of  the  subcutaneous  fibro- cellular  tissue.  The  best  example 
is  the  condition  known  as  Molluscum-Fibrosum  or  Pachydermatoccele  of 
the  scalp  and  neck.     In  this  condition  the  skin  is  loose,  filled  with  slack 


Fig.  27.     Keloid  in  a  scar. 
(Kindly  lent  by  Dr.  Gilbert  Scott) 


:•!  \  TEXTBOOK  OF  SURGERY 

fibrous  tissue  and  bangs  in  pendulous  folds,  closely  allied  to  this  is  the 
uncommon    neurofibromatosis    01    von    Recklinghausen's    disease.     The 

common  translucent,  grey,  nasal  polypus  is  by  some  considered  to  belong 
to  this  group,  but  these  are  now  more  often  regarded  as  of  inflammatory 
origin. 

(c)  KELOID.  This  term  is  applied  to  excessive  formation  of  fibrous 
tissue  in  a  sear.  In  many  instances  this  is  rather  of  chronic  inflammatory 
origin  than  a  neoplasm.  The  condition  is  fairly  common  in  tuberculosis, 
e.g.  in  the  scar  left  after  removal  of  tuberculous  glands  of  the  neck.  The 
scar  becomes  prominent  and  forms  a  tough,  elevated  mass,  reddish  in 
colour,  the  skin  over  it  being  adherent.  Excision  is  to  be  avoided  in  such 
cases  lest  a  larger  keloid  result  ;  application  of  X-rays  will  often  effecl  a 
cnre.     (Fig.  27.) 

Fibromas  of  old  standing  often  undergo  degeneration  of  a  myxomatous 
or  necrotic  nature,  and  calcification  or  even  production  of  bone  or  cartilage 
may  take  place  ;   mention  has  already  been  made  of  sarcomatous  changes. 

2.  LIPOMA 

These  tumours  are  formed  of  fatty  tissue  and  are  found  in  two  forms  : 
(a)  the  Circumscribed  ;   (b)  the  Diffuse. 

(a)  Circumscribed  lipomas  are  well-defined  encapsuled  tumours  found 
as  soft,  lobulated  swellings  with  a  well-defined  edge,  which  readily  slips 
away  from  the  examining  finger  on  palpation.  They  can  readily  be  enucleate*  1 
and  do  not  recur  after  removal.  They  are  often  subcutaneous  on  the  back', 
shoulders  and  buttocks.  Another  more  important  situation  is  in  the  extra- 
peritoneal fatty  tissue  (subserous  lipomas),  wdiere  they  may  be  the  origin 
of  hernial  protrusions  (vide  fatty  hernia,  lipoma  of  the  spermatic  cord). 
Less  commonly  they  are  connected  with  internal  organs  as  the  kidney. 
Lipomas  originating  under  the  periosteum  (parosteal  lipoma)  are  of  import- 
ance in  their  resemblance  to  periosteal  sarcomas.  Their  slower  growth 
and  softness  will  usually  serve  to  distinguish  them  from  sarcomas,  but  in 
doubtful  cases  exploration  should  always  be  done  before  resorting  to  drastic 
measures,  such  as  amputation. 

The  stroma  may  be  modified,  when  we  get  such  combinations  as  fibro- 
lipoma,  nsevo-lipoma,  &c. 

(b)  Diffuse  lipomas  or  collections  of  fatty  tissue  without  a  capsule  may 
be  of  racial  origin,  as  in  the  fatty  tumours  found  on  the  buttocks  of  ceil  a  in 
African  tribes  (steatopygy)  ;  in  other  cases  these  may  occur  associated 
with  general  obesity,  and  then  often  in  the  loose  tissue  of  the  back  and 
sides  of  the  neck. 

In  joints  excess  of  fatty  tissue  in  the  synovial  fringes  is  important, 
leading  to  locking  of  joints,  arthritic  changes,  &c. 

The  treatment  is  enucleation  in  the  localized  forms  ;  in  the  diffuse  forms 
diet,  exercise,  and  thyroid  extract.  The  latter  line  of  treatment  has  been 
of  use  in  the  fatty  involvement  of  synovial  fringes  of  joints. 


OSTEOMA 


95 


3.  CHONDROMA 

Tumours  of  pure  cartilage,  i.e.  not  part  of  some  more  complex  growth 
as  endotheliomas,  mixed  tumours,  sarcomas,  &c,  are  not  common,  and 
always  grow  in  connexion  with  bones,  especially  on  the  long  bones  of  the 
hands  and  feet,  i.e.  metacarpals  and  metatarsals,  less  often,  on  the  long 
bones  of  the  limbs.  They  are  well-defined  encapsuled  tumours,  causing 
pressure  atrophy  of  the  bone,  from  which  they  grow.  They  can  be  readily 
enucleated  in  most  instances.  Their  position  on  the  metacarpals  and  pha- 
langes, their  slow  growth, 
hardness,  and  multiplicity 
will  render  diagnosis  easy 
in  typical  cases ;  radio- 
grams may  be  helpful  in 
less  obvious  conditions. 

The  formation  of  carti- 
lage in  the  synovial  fringes 
of  joints,  or  as  outgrowths 
from  the  ribs,  nasal  sep- 
tum, laryngeal  and  tracheal 
cartilages  is  rather  of  the 
nature  of  local  hypertrophy 
or  inflammation  than  new 
growth. 


^1-v 


Fig.  28.     Myeloid  sarcoma  (magnified). 


4.    OSTEOMA 

These  will  be  more 
fully  described  in  the  sec- 
tion on  Affections  of  Bone. 
It  is  enough  here  to  mention 
that  such  bony  tumours  are 

not  encapsuled,  but  are  of  typical  structure  as  regards  cellular  elements,  and 
may  be  formed  of  compact  or  cancellous  bone.  The  latter  is  by  far  the  more 
common  condition,  and  the  tumours  are  usually  known  as  exostoses.  Exos- 
toses originate  close  to  the  ends  of  long  bones  growing  from  a  cap  of  cartilage, 
which  probably  represents  a  portion  of  displaced  epiphyseal  cartilage,  since 
growth  of  these  exostoses  ceases  at  the  date  when  the  epiphyses  unite. 
Further  should  be  noted  the  production  of  bone  in  muscle  (myositis  ossi- 
ficans) ;  the  secondary  formation  of  bone  in  other  tumours,  as  fibromas, 
chondromas  ;  and,  above  all,  in  sarcomas  arising  from  bone. 

5.   TUMOURS  ARISING   FROM  BONE-MARROW 

These  form  a  large  and  pathologically  an  extremely  interesting  group. 
Surgical  regard,  however,  is  at  present  confined  to  one  class.  The  following 
conditions  are  found  : 

(a)  Giant-celled  sarcoma  ;   (b)  Myelomatosis  ;  (c)  Myelogenous  leukaemia  ; 


96  A  TKXTI'.ooK   <>K  SIROHHY 

(d)  Chloroma.     ( »t  tin-  tun  latter  it  is  enough  to  say  that  they  belong  to  the 
group  "f  "  IiI.hhI  diseases."  and  are  described  m  medical  works. 

(a)  Giant-celled  Sarcoma,  Myeloid  Sarcoma  or  Myeloma,  as  it  is  often 
called,  is  characterized  by  the  formation  of  local  t  nmours  in  t  he  hone-marrow, 
especially  in  the  cancellous  portions  of  the  long  hones.  These  tumours 
consist  largely  of  giant,  multinucleate  cells  (myeloplaxes)  in  a  matrix  of 
spindle  and  other  cells.  They  are  of  a  maroon  colour  and  fairly  well  localized, 
but  cause  local  destruction  of  the  bone  by  their  invasion  and  expansion, 
giving  rise  to  spontaneous  fractures.  They  are  essentially  local  and  benign, 
do  not  form  metastases  unless  sarcomatous  changes  have  taken  place,  and 
are  curable  by  local  removal,  such  as  excision,  or  even  thorough  curetting 
and  painting  with  pure  carbolic.  (Fig.  28.) 

(b)  Myelomatosis  or  multiple  myelomata  consists  in  a  diffuse  infiltration 
and  alteration  of  the  bone-marrow  into  red  or  reddish-grey  tumour  masses. 
Fracture  and  distorsions  of  bones  are  common  ;  albumose  is  found  in  the 
urine,  and  severe  anaemia  of  a  secondary  type  is  present.  The  structure 
of  the  tumours  in  the  marrow  is  of  relatively  small  cells,  giant  cells  being 
absent. 

6.  TUMOURS   OF  LYMPH-GLANDS.     LYMPHOMA 

These  belong  to  the  department  of  internal  medicine.  In  the  section 
on  Vascular  Surgery  a  short  account  is  given  of  Lymphadenoma  (Hodgkhfs 
disease),  Leukaemia,  and  Lymphosarcoma.  The  surgery  of  the  spleen  is 
discussed  in  the  section  on  the  Upper  Abdomen. 

7.  MYOMAS     (LEIOMYOMA) 

Tumours  of  the  unstriped  muscle  are  rare  except  in  the  uterine  wall, 
where  they  are  common  enough,  but  they  occasionally  appear  in  the  ovary, 
prostate,  and  intestinal  wall.  They  consist  of  concentric  whorls  of  smooth 
muscle  spindles  or  fibres,  forming  dense,  well-defined  and  encapsuled 
tumours,  easy  of  enucleation.  There  is  a  considerable  amount  of  fibrous 
tissue  present  in  addition  to  the  smooth  muscle  fibres,  giving  on  section 
an  appearance  aptly  compared  to  wTatered  silk,  and  the  alternative  names 
of  uterine  fibroid  or  fibromyoma.  These  growths  are  liable  to  undergo 
degeneration  from  failure  of  their  blood-supply,  which  when  aseptic  is 
known  as  "  necrobiosis  "  or  red  softening,  and  which  may  end  in  sloughing 
should  infection  take  place,  otherwise  cyst  formation  is  likely  to  follow. 
Less  often  calcification  or  sarcomatous  degeneration  is  noted. 

(d)  Typical  Hylic  Tumours  of  Mesothelial  Origin.  Rhabdomyomas 
or  tumours  of  striped  muscle  are  usually  found  as  part  of  a  mixed  tumour 
originating  in  pleuripotent  cells.  Rarely  are  tumours  of  pure  striped  muscle 
found  in  connexion  with  the  kidney,  testis,  &c,  and  need  only  be  mentioned 
to  complete  the  survey  of  the  subject. 


SARCOMAS 


97 


II.  ATYPICAL  HYLIC  TUMOURS 

(a)  Myxomas.  Since  myxomatous  tissue,  which  consists  of  fine,  deli- 
cately branching  cells  lying  in  a  soft,  homogeneous  matrix,  is  only  normally 
found  in  embryos  and  never  in  adults,  and  embryonic  tumours  are  essentially 
atypical,  it  is  doubtful  if  myxomas  should  be  classed,  as  they  often  are, 
with  non-malignant  tumours,  especially  as  myxomatous  tissue  is  nearly 
always  found  in  sarcomas  or  in  degenerating  conditions  of  a  suspicious 
nature.  Further,  tumours  which  have  been  regarded  as  purely  myxomatous, 
such  as  nasal  polypi,  are 
most  probably  not  new 
growths  at  all,  but  in- 
flammatory conditions, 
i.e.  inflamed  cedematous 
mucosa.  In  practice,  the 
presence  of  myxomatous 
tissue  in  tumours  is  gener- 
ally to  be  regarded  as 
evidence  of  malignancy. 

(b)  Sarcomas.  These 
tumours  are  formed  of 
rapidly  growing  embry- 
onic, atypical  cells  of  the 
connective-tissue  or  hylic 
variety,  i.e.  with  an  inter- 
stitial substance  of  fibril- 
lar, granular  or  homogen- 
eous material.  The  cells 
are  derived  from  forerun- 
ners of  hylic  nature,  in 
most  instances  of  mesen- 
chymatous  origin,  but  also, 
as  has  been  mentioned  under  Glioma  and  Chordoma,  of  epiblast  or  hypo- 
blast. In  addition,  such  sarcomatous  cells  may  originate  in  lepidic  or 
epithelial  cells,  especially  where  these  are  of  mesothelial  origin  as  has  been 
pointed  out  under  Transitional  Lepidomas  or  Mesotheliomas. 

The  cells  of  sarcomas  are  of  various  sizes  and  shapes.  In  general,  the 
more  vegetative  or  embryonic,  i.e.  the  less  differentiated  the  cells,  the  more 
atypical  in  fact,  the  more  rapidly  growing,  invading,  and  malignant  are 
such  tumours. 

This  last  statement  must  not,  however,  be  taken  too  literally,  since  the 
malignancy  of  a  sarcoma  depends  also  on  the  site  of  origin,  or  rather  on  the 
sort  of  tissue  in  which  origin  takes  place.  Sarcomas  of  slow  growth  may 
possess  a  capsule,  though  this  is  less  distinct  than  in  innocent  tumours, 
and  on  close  examination  (microscopical)  the  active  cells  are  seen  to  have 
a  tendency  to  spread  through  such  a  capsule.  The  blood-supply  is  abundant. 
1  7 


Fig.  29.     Myxosarcoma  (magnified).  Columns  of  spindle- 
and  oat-shaped  cells  are  noted  amongst  areas  of  myxoma- 
tous degeneration  containing  branching  cells. 


\  TEXTBOOK  OF  SURGERY 

as  sarcomas  may  he  regarded  as  a  mesh-work  of  dilated  capillaries,  usually 
badly  formed,  around  and  between  which  are  situated  the  actively  growing 
sarcoma  or  principal  cells.  This  close  relation  of  the  cells  to  the  blood- 
vessels explains  their  ready  dissemination  by  the  blood-stream,  secondary 
deposits  in  the  lungs  being  characteristic  of  sarcomas.  Owing  to  the 
inferior  manner  in  which  the  blood-vessels  are  formed.  Inemorrhages  into 
the  substance  of  the  growth  are  common.  In  addition,  metastases  may 
also  take  place  along  the  lymphatics  in  the  lymph-nodes,  though  not  so 
frequently  as  in  cancer.     Secondary  deposits  in  lvmph-nodes  are  specially 


Fio.  30.     Round-celled  sarcoma  invading  muscle  (magnified). 

noted  in  sarcoma  of  the  tonsil,  thyroid,  testis,  in  lympho -sarcoma  and  in 
melanoma,  winch  is  sometimes  classed  with  sarcomas. 

Varieties  of  Sarcoma.  Sarcomas  may  be  divided  into:  (1)  Pure, 
and  (2)  Mixed,  in  accordance  with  their  structure.  In  tin1  former  varieties 
the  cells  throughout  the  growth  arc  very  similar  in  character  ;  in  the  latter 
the  tumour  may  be  the  result  of  anaplasia  or  departure  from  the  typical 
in  structure  of  innocent  tumours,  r.tj.  fibro-sarcoma,  or  from  the  transition 
of  the  embryonic  sarcoma  cells  into  some  nunc  differentiated  type  of  exist- 
ence, as  in  ossifying  sarcomas,  or  again  from  degeneration  of  the  cells,  as 
in  the  type  myosarcoma. 

(1)  Pure  Sarcomas.  These  are  classified  according  to  the  type  of  cells 
of  which  they  are  made,  as  round  or  spindle-celled.  Further,  these  cells 
may  he  large  or  small. 

('/)  Round-celled  sarcomas  are  divided  into  large-  and  small-celled 
varieties. 

A.  The  large  round-celled  form  is  made  up  of  cells  having  a  rounded 
nucleus  and  a  fair  amount  of  cell  body.  They  are  not  common,  and  clinically 
are  less  malignant  than  : 


SARCOMAS 


99 


B.  The  small  round-celled  sarcoma,  in  which  the  cells  have  very  little 
cell  body,  but  consist  almost  entirely  of  the  rounded  nuclei.  The 
"  lympho-sarcoma,"  starting  in  lymph-nodes,  is  of  this  type,  but  exactly 
similar  tumours  may  originate  in  any  connective-tissue  structure,  such  as 
bone. 

(b)  Spindle-celled  Sarcomas.  These  also  may  be  made  of  large  or  small 
cells,  the  latter  being  the  more  usual  type.  The  cells  of  spindle-celled 
sarcoma  are  not  arranged  in  the  regular  manner  that  obtains  in  fibromas. 
and  the  cellular  elements  are  in  far  greater  abundance  in  proportion  to  the 
interstitial  matter.  Where  the  type  of  cell  is  something  between  round 
and  spindle-shaped  the  term 
"  oat-shaped  "  is  applied  to 
the  formation. 

Some  spindle-celled  sar- 
comas are  relatively  benign, 
showing  practically  no  ten- 
dency to  form  metastases, 
and  having  some  attempt  at 
a  capsule ;  such  formations 
are  sometimes  known  as 
"  recurrent  fibroids,"  of  which 
the  "  pink  epulis  "  of  the  jaw 
is  a  common  example. 

The  naked-eye  appear- 
ances of  sarcomatous  tissue 
varies.  The  more  rapidly 
growing,  round-celled  sorts 
are  made  up  of  greyish-white, 
friable,  encephaloid  material, 
often     containing     areas     of 

haemorrhage  and  degeneration,  and  without  any  sort  of  capsule.  Spindle- 
celled  sarcomas  are  harder,  of  greyish-pink  colour,  not  unlike  fibromas  but 
less  dense,  and  usually  have  some  sort  of  capsule.  It  will  be  noted  that 
the  resemblance  of  sarcomatous  to  granulation  tissue  is  considerable  ;  but 
whereas  granulation  tissue  always  has  some  definite  ending,  either  in  fibrous 
tissue,  suppuration,  necrosis,  &c,  in  sarcoma  there  are  masses  of  cells  in 
the  same  stage,  which  simply  go  on  dividing  and  have  little  tendency  to 
mature  in  any  direction,  but  invade  the  surrounding  tissues.  And  whde 
in  inflammatory  foci  there  are  always  some  points  where  mature  fibrous 
tissue  is  being  formed  and  well-developed  capillaries  are  arising,  in  sar- 
comas the  capillaries  are  ill-formed  and  readily  give  way,  leading  to 
haemorrhages  into  the  mass  of  growth. 

(2)  Mixed-celled  Sarcomas.  Structural  or  Organized  Sarcomas.  This 
is  a  very  large  group  of  tumours,  widely  varying,  since  it  embraces  all 
hylic  tumours,  which  from  being  typical  have  undergone  atypical  develop- 
ment as  well  as  many  lepidic  formations  of  the  mesothelium  of  atypical 


Fig.  31 


Spindle-celled  sarcoma  (magnified). 


ioo 


\  TEXTBOOK  OF  SURGERY 


nature,  for  these  arc  in  some  part  nearly  always  sarcomatous  even  il  cancerous 
I'lscu  here. 

Sarcomas  originating  in  tin'  more  specialized  connective  tissues  in 
many  instances  have  a  tendency  to  assume  to  a  certain  degree  the  character 
of  the  structure  from  which  they  originate.  This  is  often  the  case  with 
sarcomas  of  the  periosteum  :  any  structure  which  tak<  s  pari  in  the  periosteal 
formation  of  bone  may  be  represented  in  such  a  tumour,  and  we  may  find 
round  and  spindle  cells,  cartilage,  bone,  ami  myxomatous  tissue  present. 
The  formation  of  the  more  differentiated  tissues,  however,  is  always  atypical 

and  imperfect.  In  sarcomas 
grow  ing  from  aponeuroses  this 
is  also  the  case,  the  growth 
being     of     spindle     cells,     and 

closely  related  to  fibromas,  hut 
whereas  the  osteosarcomas  are 
very  malignant,  the  variety 
originating  in  aponeuroses  (des- 
moids) are  relatively  benign. 

Sarcomas  arising  in  the 
course  of  epithelial  (lepidic) 
tumours  are  not  uncommon. 
especially  when  these  are  of 
mesothelial  origin.  Such  for- 
mations as  atypical  endo- 
theliomas of  blood-  of  lymph- 
vessels,  the  renal  mesothelioma 
(hypernephroma)  often  pass 
into  growths  of  sarcomatous 
nature,  containing  various  cell- 
elements,  round,  spindle  or 
stellate  cells,  with  a  matrix 
of  fibrils,  granular  substance,  cartilage,  myxomatous  material,  &c.  In 
this  group  will  come  some  of  the  hsemangeiosarcomas  and  alveolar 
sarcomas,  having  the  cells  arranged  in  alveoli  around  vascular  spaces  as 
well  as  melanotic  tumours  in  the  parts  which  are  not  atypically  lepidic  or 
cancerous  in  structure. 

We  add  a  brief  recapitulation  of  the  classification  of  tumours. 


mmmiiimi 


Fig.  32. 


Fibro-sarcoma  (magnified), 
pharyngeal  polypus. 


Naso- 


(1)  Teratomas. 

A.  Ovarian. 

('/)  Cystic   (ovarian   dermoids). 
(//)  Solid  (embryomas). 

B.  Testicular,  including  most  tumours,  innocent  and  malignant. 

C.  Festal  inclusions,  e.g.  congenital  sacrococcygeal  tumour. 

(2)  Teratoblastomas  or  mixed  tumours. 

A.  Renal  mesotheliomas  (hypernephromas). 


CLASSIFICATION  OF  TUMOURS  101 

B.  Salivary    (mixed    parotid    tumours,    sometimes    called    endo- 

theliomas). 

C.  Odontomes. 
(3)  Blastomas. 

(a)  Heterochthonous  (Chorioepithelioma). 


'-"v-  'W\     ~-:"    :>ir:^-<  V;-"-.-'-, :-..•/«' 


Fig.  33.     Endo-  or  perithelioma  (magnified)  is  practically  a  fibro-sarcoma 
originating  in  the  wall  of  lymphatics. 

(b)  Autochthonous. 

(c)  Autochthonous  Blastomas. 

A.  Pure    lepidomas    (epithelial  tumours)  derived  from  epi-.   hypo-. 
and  mesoblast. 

(a)  Papillomas. 
Typical. 

(1)  Warts,  corns,  condylomas  (blastomatoid). 

(2)  Soft  papillomas  of  non-irritative  origin. 

(3)  Intracystic  papillomas. 

(b)  Adenomas. 

(c)  Atypical  lepidomas,  cancers,  carcinoma. 

( 1 )  Squamous-celled. 

(a)  Warts. 

(6)  Ulcers. 

{e)  Cauliflower  iriowths. 

(d)  Solid  plaques. 

(2)  Spheroidal  celled. 


102  \   rEXTBOOK  OF  SURGERY 

((/)  Cancer,  atropine,  scirrhus,  simple,  encephaloid,  Sec. 
(It)  Rodenl  ulcer. 
(.'))  Columnar  celled  cancer  and  tnalignanl  adenomas. 
K  Transitional  lepidomas. 

(1)  Mesotheliomas. 

(a)  Renal. 

(h)  Of  serous  surfaces  (sometimes  called  endothelioma). 

(2)  Endotheliomas. 

(a)  Typical  Angeiomas. 

(1)  Vascular. 

(a)  Capillary  (birth-marks). 

(6)  Cavernous. 

(c)  Cirsoid  aneurysm. 

(2)  Lymphatic. 

(a)  Capillary  (moles). 

(b)  Cavernous. 

(c)  Cystic  hygromas. 

(b)  Atypical  endotheliomas. 

(c)  Melanomas,  melanotic  epithelioma,  carcinoma. 
C.  Hylomas  or  pulp  tumours. 

(1)  Typical. 

(a)  Epiblastic. 

(1)  True  neuroma. 

(2)  Glioma. 

(6)  Hypoblastic  (chordoma). 
(c)  Mesoblastic. 

(1)  Fibroma. 

A.  Hard. 

B.  Soft  and  Fibromatosis. 

C.  Keloid. 

(2)  Lipoma. 

A.  I  lircumscribed. 

B.  Diffuse. 

(3)  Chondroma. 

(4)  Osteoma. 

A.  Compact. 

B.  Cancellous. 

(5)  Tumours  of  bone  marrow. 

A.  <  riant  celled  sarcoma. 

B.  .Myelomatosis. 

C.  Leukaemia. 

D.  Chloroma. 

(6)  Lymphomas. 

(<l)  Mesothelial,  rhabdomyoma. 

(2)  Atypical. 

(a)  Myxoma. 


DIAGNOSIS  OF  TUMOURS  103 

(b)  Sarcoma. 

(1)  Pure. 

(a)  Round  celled. 

(b)  Spindle  celled. 

(c)  Oat-celled. 

(2)  Mixed  and  structural  sarcomas. 

DIAGNOSIS  OF  TUMOURS 

Tumours  have  to  be  distinguished  from  the  results  of  inflammation, 
usually  of  a  subacute  or  chronic  nature,  from  hypertrophy,  cysts,  &c, 
and  further  differentiated  with  regard  to  the  sort  of  tumour  present.  The 
history,  especially  as  regards  onset  and  rate  of  growth,  is  important.  The 
relation  to  surrounding  structures,  such  as  bones  and  viscera,  and  the  local 
examination  with  regard  to  hardness,  mobility,  definition,  and  X-ray 
examination,  especially  in  the  case  of  bones,  will  give  some  clue.  The 
examination  of  the  area  of  lymphatic  drainage  for  secondary  enlargement 
of  lymph-nodes,  and  of  the  liver  and  lung  for  metastatic  deposits,  will  often 
settle  the  diagnosis  ;  though  if  diagnosis  is  made  onlv  when  metastases  have 
appeared  it  will  be  of  little  use,  since  the  period  of  possible  cure  is  almost 
certainly  at  an  end.  Often  exploration  will  be  needed,  and  in  difficult  cases 
microscopical  examination  of  portions  of  the  tumour.  This  will  settle  the 
matter  readily  enough  when  the  tumour  is  epithelial  (lepidic),  but  sarco- 
matous masses  are  often  difficult  to  distinguish  from  inflammatory  conditions 
unless  large  portions  are  removed  and  examined  in  detail. 

In  many  cases  diagnosis  largely  turns  on  the  situation  of  the  growth 
and  will  be  discussed  under  the  surgery  of  Regions  and  Organs. 

TREATMENT  OF  NEW  GROWTHS 

This  will  differ  according  to  the  nature  of  the  tumours,  which  may  be 
divided  for  practical  purposes  into  the  innocent,  the  definitely  malignant, 
and  the  locally  malignant  or  quasi-malignant. 

(1)  Innocent  growths  need  removal  either  beoause  they  interfere  with 
comfort,  as  may  be  the  case  with  large  lipomas,  or  interfere  with  normal 
functions,  as  with  adenoma  of  the  prostate  and  thyroid,  or  because  they 
are  likely  to  undergo  malignant  changes,  as  in  the  case  of  warts  of  the  lip 
and  tongue  in  middle  aged  persons.  Thus  lipomas  have  little  tendency  to 
become  malignant,  and  unless  inconvenient  or  painful  (from  their  position), 
or  unless  the  diagnosis  is  uncertain,  as  in  parosteal  lipoma,  may  sometimes 
be  let  alone.  As,  however,  such  tumours  grow  indefinitely,  in  most  instances 
the  patient  wilJ,  sooner  or  later,  desire  their  removal,  and  it  is  best  therefore, 
as  a  general  rule,  to  remove  innocent  tumours  unless  there  is  some  manifest 
contra-indication,  such  as  a  general  condition  of  ill  health  rendering  opera- 
tion dangerous.  Such  tumours  if  encapsuled  can  be  readily  shelled  out ; 
if  continuous  with  the  surrounding  tissues,  as  in  the  case  of  osteomas  and 
nsevi,  they  must  be  cut  away  completely.  In  the  latter  instance  a  tolerably 
wide  removal  is  needed  to  ensure  complete  cure. 


Ml 


\  TEXTBOOK  OF  SURGERY 


(■_')  Where  the  tumour  is  of  slight  or  uncertain  malignancy,  e.g.  giant- 
celled  sarcoma  or  the  pink  epulis  <>f  the  jaw,  removal  should  be  complete, 

taking  a  small  margin  of  healthy  tissue  with  the  tumour,  <>r  cauterizing  the 
Bite  of  removal  with  pure  carbolic  or  other  caustic. 

(.'i)  Where  the  tumour  is  definitely  malignant  the  most  certain  method 
ot  cure  known  at  present  is  by  suitable  operative  measures.  Such  tumours 
should  he  removed  freely,  with  a  large  surrounding  margin  of  apparently 

healthy  tissues,  together  with 
the  areas  of  lymphatic  drain- 
age and  the  lymph  nodes 
which  appertain  thereto  :  the 
whole  to  be  removed  in  one 
mass  if  possible.  Unfortun- 
ately, this  counsel  of  perfec- 
tion is  only  possible  in  certain 
situations,  and  practically 
never  in  entirety,  there  being 
paths  of  possible  infection 
(usually  lymphatics)  quite 
out  of  the  reach  of  surgical 
endeavour.  Nevertheless  the 
results  are  surprisingly  good 
where  this  plan  can  be  car- 
ried out  early  and  with  any- 
thing approaching  exactitude, 
e.g.  in  the  case  of  the  breast 
and  in  certain  growths  of  the 
intestinal  tract.  Early  diag- 
nosis is  the  all  important 
desideratum  if  such  measures 
are  to  be  successful.  Hence 
the  importance  of  early  ex- 
plorations in  cases  where  signs 
point  to  disease  of  parts  in  which  malignant  disease  is  likely  to  occur,  e.g.  the 
stomach  and  intestine.  In  many  cases  operative  treatment  to  he  effective 
must  be  decidedly  mutilating,  leaving  the  patient  deprived  of  a  limb  or 
dependent  on  some  exotic  form  of  existence,  e.g.  with  a  colostomy.  In  the 
future  the  treatment  of  malignant  disease  will  probably  be  by  other  methods, 
of  which  the  radial  ions  and  certain  toxic  substances  show  possibilities, 
though  at  present  these  are  so  much  less  effective  than  operative  treatment 
that  they  are  inadvisable  except  in  certain  classes  of  malignant  disease, 
where  operative  treatment  is  out  of  the  question. 

The  effects  of  X-rays  and  radium  on  malignant  tumours  is  in  many 
cases  quite  extraordinary,  whether  by  destroying  the  malignant  cells  or  by 
exciting  the  tissues  to  a  greater  natural  reaction  is  uncertain.  Temporary 
"cures''  are  by  no  means  uncommon  by  the  use  of  either  method,  large 


Fro.  34a. 


Sarcoma  of  the  upper  jaw  (round-celled) 
encroaching  on  the  orbit. 


TREATMENT  OF  TUMOURS 


105 


masses  of  growth  disappearing  in  a  few  weeks  under  their  influence,  and 
even  where  the  tumour  does  not  disappear,  relief  of  pain  and  cleansing  of 
ulcerated  surface  often  results. 

These  radiations  may  be  used  to  supplement  operative  treatment  ;  thus 
in  cancer  of  the  breast  half  a  dozen  exposures  to  X-rays  applied  through 
an  aluminium  screen  after  operation  is  well  worth  a  trial  to  destroy  any 
cancer  cells  which  may  have  been  left  inadvertently  in  the  vicinity  of  the 
operation.  Radium  has  the 
advantage  over  X-rays  in  that 
tubes  containing  this  sub- 
stance can  be  left  for  several 
hours  in  hollow  viscera,  or 
introduced  into  solid  tumours 
by  means  of  incisions,  so  that 
a  great  effect  is  produced.  In 
other  respects  the  effects  of 
radium  and  those  of  X-rays  are 
very  similar,  though  X-rays 
have  the  great  advantage  at 
present  of  being  much  less 
expensive.  While  these 
means  are  not  advisable  at 
present,  if  a  tumour  is  oper- 
able much  relief  and  apparent 
cure  may  often  be  obtained 
by  their  use  in  otherwise 
hopeless  cases,  and  with 
further  development  of  tech- 
nique we  may  hope  for  still 
further  improvement  in  the 
future.  X-rays  are  most  suit- 
able for  the  cure  of  rodent 
ulcers     and     for     alleviating 

metastatic  deposits  in  cancer  of  the  breast  and  in  sarcomas  where  temporary 
cure,  at  least,  of  tumours  is  frequently  reported.  The  results  in  cases  of 
squamous-celled  cancer  of  the  tongue,  pharynx,  intestine.  &c,  are  less 
satisfactory  under  X-rays,  though  some  successes  with  radium  are  recorded. 

Of  toxic  substances  caustics,  trypsin,  and  many  others  have  been  tried 
and  found  wanting.  The  only  substance  of  this  sort  at  present  in  vogue 
is  Coley's  fluid,  which  is  a  mixture  of  the  toxins  of  streptococci  and  those 
of  the  bacillus  prodigiosus.  In  some  cases  of  sarcoma  Coley  has  obtained 
cures  of  such  duration  that  they  may  fairly  be  regarded  as  complete  ;  other 
workers  have  had  less  satisfactory  results,  whether  from  improper  technique 
or  from  unsuitable  cases  it  is  impossible  to  say.  Only  a  small  proportion 
of  the  cases  respond  to  this  treatment.  The  cases  which  respond  best  to 
this  method  are  sarcomas,  and  the  rationale  of  the  treatment  is  based  on 


Fig.  34b.     Sarcoma  of  the   upper  jaw  after   tying 

the  external  carotid  artery  and  heavy  dose  of  X-rays 

(temporary  recession  of  growth). 


L06  A  TEXTBOOK  OF  SURGERY 

the  well-known  observation  of  the  regression  of  Barcoma  in  patients  when 
Buffering  from  an  attack  of  erysipelas.  Coley's  fluid  is  given  by  hypodermic 
injections  of  small  doses,  starting  with   ,',,-!  minim  and  gradually  increasing 

lip  to    1(1   minima ;     to   produce  Satisfactory    results   it    will   be   necessary   to 

cause  great  constitutional  disturbance  in  the  shape  of  high  fever,  rigors, 
and  marked  general  depression.  We  figure  a  case  of  round-celled  sarcoma 
of  the  upper  jaw,  spreading  into  the  nose  orbit,  palate  and  temporal 
region  obviously  inoperable.  After  the  injection  of  boiling  water  into  the 
external  carotid  (to  diminish  the  blood-supply  of  the  tumour),  giving  Coley's 
fluid  and  heavy  doses  of  X-rays  through  an  aluminium  screen,  the  growth 
disappeared  completely  as  far  as  could  be  ascertained  for  about  four  months, 
but  later  recurred,  proving  fatal  wit  bin  the  year  ;  such  "  cures  "  are  only  too 
frequent.  Still  they  suggest  the  hope  that  in  future  years  the  non-operative 
treatment  of  malignant  disease  may  he  quite  successful. 

Treatment  of  Inoperable  Cases  of  Malignant  Disease.  Operative 
treatment  may  often  be  of  service.  Thus  fungating,  noisome,  malignant 
ulcers  may  be  excised  quite  properly  if  there  is  some  prospect  of  local  healing 
after  operation,  and  if  the  general  health  is  moderate,  even  though  the 
presence  of  metastases  in  the  viscera  show  that  complete  cure  is  impossible. 
Where  the  growth  interferes  with  the  function  of  some  important  viscus, 
e.g.  stenosis  of  the  intestine,  pylorus,  or  larynx  operative  relief  by  short- 
circuiting  the  obstruction,  colostomy,  tracheotomy,  &c,  are  clearly  indicated. 
In  the  last  stages  the  use  of  X-rays  and  antiseptics,  such  as  orthoform, 
for  malignant  ulcers  and  finally  the  relief  of  pain  by  morphia  and  other 
anodynes  are  our  only  resource. 

CYSTS 

The  term  cyst  includes  a  very  diverse  collection  of  swellings  having 
only  one  character  in  common,  viz.  that  they  are  cavities  containing  fluid. 
Differing  as  they  do  genetically  and  pathologically  the  conception  of  a  cyst 
varies  with  the  mentality  of  the  writer. 

A  large  number  of  well-circumscribed  swellings  filled  with  fluid  are  by 
common  consent  not  termed  cysts,  e.g.  acute  and  most  chronic  abscesses, 
traumatic  effusions  of  blood  (hematoma),  aneurysms,  &c.  On  the  other 
hand,  extravasations  of  blood  in  certain  localities  are  known  as  cysts,  e.g. 
arachnoid  cysts,  blood  cysts,  &c. 

Since  these  si  pictures  have  no  real  causal  connexion,  scientific  classifica- 
tion is  not  possible.  A  cysl  may  briefly  be  defined  as  an  encapsuled  tumour 
containing  fluid,  usually,  hut  by  no  means  invariably,  lined  with  epithelium 

or  endothelium,  and    not    the   immediate  result  of  acute  infla tation  or 

trauma.  Jn  some  instances  they  are  identified  by  their  contents,  as  blood, 
lymph,  cVc.  ;  jn  others  by  their  origin  as  congenital;  in  others,  again,  by 
their  mode  of  formation,  e.g.  retention  from  blocking  of  the  ducts  of  a 
gland. 

The  following  list  includes  most  varieties:  A.  Embryonic;  B.  Inflam- 
matory;  C.  Parasitic  ;   D.  Glandular  ;    E.  Degeneration. 


CYSTS  107 

A.  Embryonic  or  Developmental  Cysts.  Cysts  may  arise  from 
various  errors  in  the  development  of  the  embryo,  which  may  not  be  obvious 
till  the  subject  of  them  is  well  advanced  in  adult  life.  The  main  conditions 
of  maldevelopment  are  as  follows  : 

(a)  Improper  closure  of  embryonic  ducts  and  apertures,  accounting  for 
the  median  cervical  or  thyroglossal  cyst,  branchial  cysts  and  urachal  or 
allantoic  cysts  (the  tubulo-dermoids  of  Bland  Sutton). 

(b)  Improper  coalescence  of  parts  originally  separate  giving  rise  to 
cysts  in  the  position  where  were  originally  fissures,  as  in  dermoids  of  the 
outer  angle  of  the  orbit  of  the  skull,  and  such  conditions  as  meningocceles 
of  the  brain  or  spinal  cord  (spina  bifida),  the  first  variety  being  known 
as  sequestration  dermoids  by  Sutton. 

(c)  Improper  development  of  glandular  organs,  e.g.  failure  of  the  secreting 
portion  of  the  kidney  to  join  the  conducting  tubules  growing  from  the 


^^0M0r  ^§r  »<*-  ^-.^^^^^ 


Fig.  35.     Wall  of  a  sebaceous  cyst  (magnified),  epithelial  lining  containing  a  mass 
of  amorphous  contents. 

Wolffian   duct,   resulting   in    the    condition   known    as   congenital  cystic 
kidney. 

(d)  Stenosis  of  the  ducts  of  secreting  glands  from  congenital  defects, 
such  as  kinks,  twists,  valves,  &c  ;  many  cases  of  hydronephrosis  fall  into 
this  category. 

(e)  Improper  development  of  the  teeth  accounting  for  odontomes,  which 
are  often  cystic. 

(/)  Stenosis  of  various  hollow  organs  or  channels,  e.g.  of  lymph  spaces 
leading  to  the  formation  of  lymphatic  cysts  or  hygromata. 

(g)  Neoplastic  cysts  of  developmental  origin  as  ovarian  dermoids. 
B.  Inflammatory  Cysts  of  various  sorts  : 

(a)  Arising  around  a  foreign  body,  such  as  a  piece  of  glass  or  a 
bullet. 

(b)  Arising  from  repeated  trauma,  as  in  the  formation  of  adventitious 
bursas  from  friction  over  bony  prominences,  or  the  enlargement  of  normal 
bursas  from  similar  causes. 

(c)  Chronic   inflammation   of  infective   origin.     Cysts   connected   with 


1'  - 


\  TEXTBOOK  OF  SURGERY 


joints  are  oi  this  variety  (Baker's  cysts),  and  likewise  some  bursal  cysts. 
Certain  chronic  abscesses  are  often  described  as  cysts,  e.g.  dental  cysts, 
Borne  pancreatic  cysts.  <  ranglia  may  be  of  this  nature  if  not  purely  degenera- 
tive in  origin.  They  are  tense  swellings  connected  with  the  serous  lining 
of  joints  or  tendon-sheaths,  containing  a  viscid  or  jelly-like  material  in 
which  are  a  few  cells.     Closely  allied  to  this  group  are  : 

C.  Parasitic  <  vsts.     In  these  instances  the  cysi  is  entirely  parasitic 

and  iii  no  way  a  product  of  the  tissues.     The  hydatid  or  echiococcus  is  the 

besi  example,  but  on  a  smaller 
scale,  the  cysts  caused  by  the 
trichina  deserve  mention. 

Implantation  Cysts  are  allied 
to  both  the  two  last  groups,  and 
are  the  result  of  the  driving  of  a 
portion  of  epithelium  into  the  deeper 
tissues,  where  it  continues  to  grow. 
forming  a  cyst  containing  desqua- 
mated epithelium,  and  closely  re- 
sembling a  dermoid  cyst.  Hence 
these  cysts  are  often  called  "  im- 
plantation dermoids." 

D.  Gland  Cysts,  derived  from 
glands  or  hollow  viscera  lined  with 
glandular  epithelium.  These  may 
be: 

(a)  Retention  cysts  due  to  block- 
ing of  the  duct  of  a  gland,  as  seba- 
ceous cysts,  ranulse,  galactocoeles  of 
the  breast,  cystic  distension  of  the 
gall-bladder  (hydrops  vesicae  fella?), 
hydrosalpinx,  the  two  latter  in- 
stances being  closely  allied  to 
inflammatory  conditions. 

(6)  ( lystS  also  occur  in  ductless 
glands,  e.g.  the  thyroid,  in  some 
cases  being  degenerative,  in  others 

due  to  new  growth  (adenomas). 

(c)  New  growths  occurring  in  glands  account  for  many  cysts  lined  with 
characteristic  epithelium,  and  sometimes  called  "cystomas."  The  ovary 
is  the  mosl  common  seat  of  such  cysts,  but  they  are  frequenl  also  in  the 
breasl  and  thyroid. 

B.  Degeneration  Cysts  result  from  colliquative  necrosis  of  an  aseptic 

nature  due  to  local  malnutrition,  which  is  likely  to  lake  place  in  anaanic 
areas,  e.g.  infarcts  of  the  brain.  Such  cysts  are  also  common  in  new  growths. 
Some  ganglia  may  be  of  this  nature. 

Mosl  of  the  above  cysts  will  be  described  under  the  headings  where  they 


Fig.  [36.     Polycystoma.     Section  of  an  ova- 
rian  cysl    (slight    magnification).     Several 
Lined  with  columnar  epithelium  and 
containing  lightly  stained  albuminoid   sub- 
stance are  seen. 


DERMOIDS  109 

occur  in  the  surgery  of  organs  or  regions.  There  remain  dermoids  and 
sebaceous  cysts  to  discuss  in  rather  more  detail. 

Sebaceous  Cysts  result  from  the  blocking  of  the  duct  of  a  sebaceous 
gland,  and  consequent  distension  of  the  duct  and  gland  behind  this  from 
collection  of  retained  secretion.  Sebaceous  cysts  are  most  common  about 
the  scalp,  face,  shoulders,  and  back.  They  consist  of  a  fibrous  outer  coat 
lined  by  squamous  epithelium  and  contain  broken-down  epithelium  and 
sebaceous  debris.  They  are  distinguished  from  dermoid-cysts  by  originating 
in  adult  or  middle  age,  being  adherent  to  the  skin,  the  latter  being  thinned 
and  frequently  reddish-purple  in  colour  though  not  inflamed,  and  often 
showing  distended  venules.  The  aperture  of  the  sebaceous  gland  affected 
can  sometimes  be  seen  on  the  apex  of  the  swelling  as  a  small  punctual. 
These  cysts  are  well  defined  and  fluctuate  ;  are  not  painful  unless  suppur- 
ation is  taking  place,  which  usually  results  at  last,  and  then  they  closely 
resemble  acute  abscesses,  but  the  history  of  a  previous  lump  of  long  standing 
in  the  situation  of  the  abscess  will  help  to  make  a  correct  diagnosis. 

Treatment.  The  cysts  are  removed  by  dissection  under  local  anaesthesia 
with  eucaine,  novocaine,  &c.  A  more  rapid  method  is  to  cut  right  through 
the  sebaceous  cyst  and  overlying  skin,  splitting  the  former  into  halves, 
which  can  then  be  rapidly  extracted  from  the  surrounding  tissues. 

Dermoids.  This  term  is  applied  to  those  cysts  of  embryonic  origin 
which  contain  epidermal  structures,  i.e.  sequestration  dermoids.  The 
tubulo-dermoids,  such  as  thyroglossal  and  branchial  cysts,  which  may  or 
may  not  contain  epidermal  structures,  are  described  under  their  situation 
in  the  surgery  of  the  neck.  The  tumours  known  as  ovarian  dermoids,  which 
are  of  quite  different  origin  and  much  more  complicated  structure,  are 
classed  with,  the  teratomas.  Dermoids  are  cysts  noted  early  in  life,  not 
attached  to  the  skin,  formed  of  a  fibrous  sac  lined  with  squamous  epithelium 
containing  pultaceous,  mortary  material,  the  produce  of  epithelial  desquama- 
tion, like  that  found  in  sebaceous  cysts,  from  which  they  are  distinguished 
as  detailed  above,  and  also  by  the  presence  of  hairs  when  the  latter  are 
present.  Their  most  common  situation  is  at  the  outer  angle  of  the  orbit. 
Dermoids  are  treated  by  removal  on  the  lines  described  for  sebaceous  cysts. 


<  11  AFTER  VII 
GENERAL   CONDITIONS   OF   SURGICAL   IMPORTANCE 

Fever  :  Delirium  :  Syncope,  Shock  and  Collapse  :  Surgical  aspects  of  General 
Intoxications  :  Alcohol  :  Renal  Disease  :  Diabetes  :  Acidosis  :  Changes  in  the 

Blood. 

FEVER,   DELIRIUM,     SHOCK,    TOXEMIAS,    BLOOD  CHANGES 

The  clinical  and  pathological  manifestations  described  in  the  present 
chapter  form  a  heterogeneous  collection,  not  necessarily  connected  with 
each  other  and  mostly  being  disorders  of  function,  which  have  a  bearing 
on  surgical  practice  ;  in  addition  changes  in  the  blood,  which  are  morpho- 
logical rather  than  functional,  are  conveniently  considered  in  this  section. 

FEVER  AND  OTHER   DISORDERS  OF  THE  HEAT-REGULATING 

MECHANISM 

The  normal  body-temperature  is  maintained  by  a  balancing  of  the  heat 
production  which  takes  place  in  the  muscles,  glands,  &c.  with  the  loss  of 
heat  by  radiation,  conduction,  and  evaporation  from  the  surfaces  of  the 
body,  lungs,  &c.  The  mechanism  controlling  this  "balance  is  situated  in  the 
basal  ganglia  of  the  brain.  Where  the  temperature  of  the  body  rises  above  the 
normal  (98*4°),  fever  is  said  to  be  present.  Whether  this  results  from  greater 
heat  production  or  diminished  loss  of  heat  or  both,  need  not  be  considered 
here.  A  fall  of  the  body  temperature  below  normal  is  less  frequently  met 
with,  but  occurs  in  various  states  of  depression,  especially  that  described 
as  collapse  or  shock. 

Degree  of  fever  or  pyrexia.  When  the  temperature  is  up  to  101°  or  less 
it  may  be  called  moderate,  when  at  103°  to  105°  as  high  fever,  while 
temperatures  of  100°  and  over  are  described  as  hyperpyrexia. 

Just  as  the  normal  temperature  varies  dining  the  course  of  the  day, 
being  highest  about  6  p.m.  and  lowest  about  4  a.m.,  so  in  fever  variations 
may  occur.  In  some  instances  the  variation  is  slight,  not  more  than  half 
a  degree  in  the  twenty-lour  hours,  when  the  fever  is  said  to  be  constant. 
Such  fever  is  seen  most  typically  in  a  case  of  lobar  pneumonia.  In  other 
instances  the  fever  may  remit,  usually  in  the  morning,  rising  again  in  the 
evening,  sometimes  being  subnormal  at  its  lowest  point.  Such  fever  if 
lasting  several  days  or  more  is  often  called  "  hectic  ""  fever,  and  t  he  tempera- 
ture is  said  to  !»•  "swinging,"  from  the  variations  recorded  on  the  chart. 
This  type  of  fever  is  common  in  cases  of  prolonged  suppuration  where 
drainage  is  present,  but  not  altogether  satisfactory,  and  some  absorption 

110 


FEVER  111 

of  toxins  is  still  proceeding.  Where  the  alterations  in  the  pyrexia  vary 
in  amount,  and  are  inconstant  in  their  periodicity,  the  fever  is  said  to  be 
irregular,  and  is  common  in  spreading  infections  or  sloughing  of  septicemic 
nature. 

Rigors  are  fairly  common  accompaniments  of  fever  when  the  rise  of 
temperature  is  very  sudden.  A  rigor  consists  of  a  sudden  feeling  of  chilliness 
or  cold  all  over  the  body,  often  called  a  "  chill,"  together  with  great  sense 
of  depression  and  general  malaise.  Such  a  patient  shivers  vigorously  ; 
the  skin  appears  anaemic,  even  blue,  and  has  the  well-known  aspect  of 
"  gooseflesh  "  the  pulse  is  feeble,  and  the  patient  may  be  seriously  collapsed. 
Meanwhile  the  temperature  rises  rapidly,  perhaps  to  104°  or  105°  in  half 
an  hour.  After  a  varying  period,  usually  about  an  hour,  the  patient  becomes 
warmer  and  feels  much  better ;  the  skin  becomes  warm  and  even  hot  as 
its  circulation  is  restored  ;  the  fever  abates  almost  as  suddenly  as  it  arose, 
often  with  the  accompaniment  of  a  drenching  sweat.  This  is  the  description 
of  a  well-marked  rigor,  but  the  milder,  shivering  attacks,  commonly  occur- 
ring in  the  course  of  infective  diseases,  are  of  the  same  nature  and  generally 
indicate  a  sudden  rise  in  the  body  temperature. 

Rigors  occur  at  the  onset  of  some  acute  fevers,  e.g.  lobar  pneumonia. 
They  may  also  occur  in  a  regular  series  daily,  or  on  alternating  days,  as  in 
malaria,  indicating  the  sudden  outburst  of  the  malarial  spores  into  the 
circulation.  In  surgical  practice  rigors  are  usually  less  regular  and  generally 
indicate  the  passage  of  emboli  from  infective  foci  into  the  blood-stream, 
pointing  to  the  onset  of  a  general  infection  or  septicaemia,  especially  if 
repeated.  Hence  rigors  are  a  sign  of  the  highest  importance,  indicating 
the  urgency  of  surgical  interference  where  this  is  feasible,  as  in  cases  of 
thrombosis  of  the  lateral  sinus,  consecutive  to  middle-ear  disease. 

Causes  of  Fever.  The  commonest  cause  of  fever  is  the  upsetting  of 
the  regulating  mechanism  by  the  absorption  of  toxins,  usually  of  bacterial 
origin,  i.e.  from  infective  diseases.  But  in  the  absence  of  such  infections 
absorption  of  effusions,  such  as  blood-clot,  will  act  on  the  heat-regulating 
centre  and  cause  mild  degrees  of  fever,  as  is  often  seen  in  the  case  of  large 
hsematomas,  closed  fractures,  &c. 

Less  commonly  the  heat-regulating  centre  is  immediately  affected  by 
injury,  such  as  blows  on  the  head  ;  most  usually  such  injury  will  cause  fall 
of  temperature,  associated  with  shock,  but  in  more  severe  lesions,  i.e.  where 
the  base  of  brain  is  lacerated,  there  may  be  very  pronounced  fever,  occa- 
sionally such  degrees  of  hyperpyrexia  as  110°  being  recorded. 

Subnormal  Temperature.  (1)  Most  commonly  this  is  a  transient  affair, 
the  result  of  some  depressing  influence,  such  as  a  severe  injury  or  operation, 
intestinal  obstruction,  more  rarely  from  ultra-severe  infections,  as  in  acute 
pancreatitis,  and  is  part  of  the  phenomenon  described  later  as  shock.  Unless 
the  patient  dies  from  the  severity  of  the  depressing  influence,  the  tempera- 
ture will  usually  rise  in  a  few  hours  (assisted  by  warmth  applied  to  the 
surface,  warm  infusions  into  veins  and  rectum,  hot  drinks),  and  fever  will 
often  occur  in  the  "  reactionary  period." 


112  \  TEXTBOOK  OF  SURGERY 

('_')  Subnormal  temperature  is  also  found  in  various  debilitating  condi- 
tions, as  chronic  heart  disease.  The  most  important  conditions  of  this  sorl 
met  with  in  surgery  are  cerebral  abscess  and  jaundice  of  obstructiv igin. 

DELIRIUM 

This  is  a  perturbation  or  abnormally  active  state  oi  the  higher  or  volitional 
and  emotional  centres  of  the  cerebrum,  and  may  be  contrasted  with  stupor, 
and  still  more  with  coma,  in  which  these  centres  are  dulled  or  completely 
in  abeyance,  though  the  condition  of  "coma  vigil  "  in  delirium  is  not  far 
removed  from  ordinary  coma  (for  coma  see  Injuries  of  the  Brain).  Several 
varieties  are  described,  but  only  one  can  readily  he  separated  from  the 
others,  viz.  delirium  tremens,  which  is  due  in  tie-  first  place  to  alcoholic 
excess. 

Delirium  Tremens.  This  may  follow  simply  as  a  consequence  of 
alcoholic  indulgence,  more  often  when  some  severe  crisis  has  1 n  expe- 
rienced by  one  who  is  in  the  habit  of  imbibing  too  freely.  (Tin's  includes 
many  who  are  by  no  means  drunkards  or  anything  approaching  that 
condition.) 

Of  such  crises,  injuries  such  as  fractures,  concussion,  or  other  cerebral 
lesions  even  of  a  minor  character,  and  surgical  operations  are  familiar 
examples. 

The  onset  of  delirium  tremens  is  gradual  ;  at  first  the  patient  is  watchful. 
alert,  suspicious  and  uncertain  in  his  actions,  sleeps  badly,  and  may  ramble 
in  his  speech  at  night.  In  a  day  or  two  the  condition  become.-  more  marked. 
there  is  a  general  tremor  of  tongue,  lips,  and  hands:  the  patient  is  very 
restless  and  excitable,  and  sutlers  from  hallucinations  of  a  terrifying  or 
noisome  nature.  He  may  imagine  that  his  attendants  are  murderers,  or 
that  he  is  overrun  with  snakes,  rats,  or  other  vermin.  Fever  may  be  present 
oi-  absent  :  the  tongue  is  coated,  the  appetite  bad.  the  bowels  confined. 
Such  patients  require  careful  watching,  as  they  are  likely  to  escape  and 
come  to  grief  by  jumping  out  of  windows  or  attacking  some  harmless  by- 
stander in  a  moment  of  excitement. 

Delirium  apart  from  alcoholism  is  mostly  the  result  of  febrile  states. 
from  infections,  or  from  head  injuries.  It  chiefly  differs  from  the  alcoholic 
form  in  the  absence  of  tremor,  and  that  the  hallucinations  are  not  of  such 
a  disgusting  or  alarming  nature.  Such  delirium  is  more  marked  at  night. 
when  the  fever  is  highest.  The  sleep  is  broken  or  absent,  and  the  patient 
mutters  with  a  varying  degree  of  coherency,  imagining  himself  in  pi 
or  with  persons  other  than  those  really  present.  In  the  daytime  such 
patients  are  often  aane  enough. 

Either  delirium  tremens  or  other  delirium  may  pass  into  a  more  severe 
form,  either  from  the  patient  being  weakened  from  past  alcoholic  excess 
or  from  the  severity  of  the  present  condition.  The  delirium  assumes  the 
••  low  muttering"  type.  In  this  condition  the  patient  lies  on  his  hack,  mutters 
incoherently  to  himself  (babbling  of  green  fields),  and  picks  constantly  and 
aimlessly  at  the  bed-clothes,  being  perfectly  unconscious  of  his  surroundings. 


DELIRIUM  113 

This  severe  stage  is  sometimes  known  as  coma  vigil,  and  is  of  grave  import, 
since  few  patients  who  pass  into  this  state  ever  recover. 

Treatment.  The  milder  forms  of  delirium  need  little  treatment,  since 
they  abate  with  the  fever,  but  if  the  patient's  strength  is  failing  from  want 
of  sleep,  hypnotics  and  moderate  stimulation  with  alcohol  should  be 
employed. 

Delirium  tremens  is  more  important,  and  a  watch  should  always  be  kept 
for  early  signs  in  plethoric,  alcoholic  persons  who  have  sustained  a  severe 
injury,  undergone  operations  of  any  magnitude,  or  suffer  with  a  severe 
infection.  It  is  important  to  note  the  early  stage  of  alertness,  restlessness, 
and  suspicion,  since  the  condition  is  readily  controlled  by  means  of  sedatives 
if  recognized  before  it  has  become  well  developed. 

In  cases  showing  the  early  signs  of  this  condition  the  bowels  should  be 
moved  freely  with  calomel  5  grains,  and  sodium  bromide  30  grains,  with 
chloral  20  grains  given  every  four  hours,  while  at  the  same  time  light, 
nourishing  diet  is  pressed  on  the  patient,  and  a  moderate  amount  of  stimu- 
lant, such  as  stout.  The  more  active  stages  can  usually  be  avoided  under 
this  line  of  treatment. 

If,  however,  this  favourable  opportunity  has  gone  by  and  the  patient 
shows  marked  signs  of  delirium,  being  wildly  active,  suspicious,  violent, 
and  tremulous,  he  must  be  carefully  watched  and  restrained  as  gently  as 
possible.  Often  seclusion  in  a  quiet  dark  room  alone  is  the  best  plan.  A 
minim  of  croton  oil  in  butter  is  given  as  a  purgative,  and  a  full  dose  of  some 
reliable  hypnotic  ;  the  safest  is  paraldehyde,  of  which  1  oz.  by  mouth  or 
2  oz.  by  rectum  form  an  adequate  dose  for  a  robust  man.  A  smaller  dose 
may  increase  the  excitement  ;  morphia  given  hypodermically  (|  grain), 
followed  by  \  grain  at  hourly  intervals,  may  be  used,  but  watch  must  be 
kept  for  signs  of  respiratory  failure  (slowing  of  the  respiration).  Hyoscine 
xthy  grain  may  also  be  used,  but  is  less  safe.  Chloral  30  grains,  chloralamide 
30  grains,  or  veronal  15  grains  may  be  used  in  less  severe  cases.  As  before, 
light  nutritious  diet  and  the  milder  forms  of  alcohol  are  beneficial.  Recogni- 
tion of  the  condition  early,  resulting  in  speedy  treatment,  is  the  secret  of 
success. 

When  the  delirium  assumes  the  low,  muttering  type,  the  patient  will 
almost  certainly  die.  The  main  indications  are  to  maintain  strength  with 
saline  infusions  into  rectum,  veins,  or  subcutaneous  tissue,  and  by  administer- 
ing soluble  food,  such  as  peptonized  milk  and  egg  by  mouth  with  the  nasal 
tube  if  necessary,  or  by  rectum.  Sleep  should  be  induced  with  carefully 
adjusted  doses  of  hypnotics,  as  detailed  above,  but  owing  to  the  weak  state 
of  such  patients  the  doses  will  be  less  than  half  those  required  in  more 
robust  subjects. 

In  severe  cases  of  delirium  special  care  is  needed  to  prevent  unnecessarv 
harm  and  increase  of  damage  to  fractures  and  operation  wounds  by  judicious 
restraint.  In  the  former  instances  placing  the  limb  in  plaster  may  be  sound 
treatment,  though  on  the  whole  we  consider  that  full  doses  of  paraldehyde 
are  best,  since  under  the  action  of  this  drug  patients  will  fall  asleep  in  five 
i  8 


114  A  TEXTBOOK  OF  SURGERT 

minutes  and  wake  many  hours  afterwards  greatly  refreshed  and  in  a  much 
better  mental  state. 

SYNCOPE,  SHOCK,  AND  COLLAPSE 

Under  the  Influence  of  (1)  energetic  stimuli  to  sensitive  parts  (e.g.  a 
Mow  on  the  stomach,  or  eveD  severe  emotional  disturbance);  (2)  rapidly 
debilitating  disease  (cholera,  acute  pancreatitis,  intestinal  obstruction), 
or  (•">)  loss  of  blood,  the  nervous  and  cardio-vascular  systems  undergo 
a  profound  depression  described  as  syncope,  shock,  and  collapse.  Wnereas 
the  older  wiiters  used  the  term  shock  to  indicate  such  a  slate  of  depression 
it'  suddenly  produced,  reserving  that  of  collapse  for  such  a  state  coming 
on  more  slowly,  the  modem  tendency  is  to  class  most  of  such  conditions. 
whether  produced  slowly  or  rapidly,  as  shock,  while  the  sudden  depression 
such  as  sometimes  occurs  in  the  course  of  a  weakening  disease  or  from 
sudden  insult  to  the  body,  such  as  fractures,  thrusting  a  needle  into  the 
pleura,  &c,  is  called  syncope  or  heart  failure. 

The  immediate  underlying  pathological  condition  in  both  shock  and 
syncope  is  the  same.  viz.  a  diminished  supply  of  blood  to  the  central  nervous 
system  owing  to  a  diminution  of  the  blood  pressure.  The  exact  manner 
in  which  this  fall  of  blood  pressure  is  produced  is  even  now  not  absolutely 
clear,  and  it  seems  likely  that  several  factors  are  present,  acting  to  a  varying 
amount  in  different  cases.  The  degree  of  shock  varies  with  the  extent  of 
injury,  the  sensitiveness  of  the  structure  involved,  and  also  very  largely 
with  the  susceptibility  of  the  patient  :  some  patients  will  suffer  almost  as 
much  shock  from  the  withdrawal  of  a  tooth  as  others  from  amputation  of 
a  limb. 

(1)  Signs  of  Shock.  These  consist  in  the  evidences  of  depression  of  all 
the  vital  functions,  varying  from  momentary  faintness  and  malaise  to 
instant  death.  In  severe  cases  the  patient  lies  very  quiet,  and  though 
conscious  takes  but  little  or  no  notice  of  his  surroundings.  The  skin  is 
cold  and  anaemic  :  the  muscles  relaxed,  flaccid,  and  powerless  ;  the  face 
pale,  drawn  and  haggard,  covered  with  cold  sweat  ;  the  eyes  vacant  and 
Lustreless,  the  pupils  dilated  and  with  sluggish  reaction  :  general  sensibility 
is  diminished  and  the  temperature  subnormal.  The  pulse  is  small  and 
rapid,  in  severe  cases  irregular  :  the  blood  pressure  low  :  respiration  shallow 
and  rapid  ;  the  secretion  of  urine  is  diminished,  and  in  severe  cases  in- 
continence of  urine  and  faeces  may  be  noted.  The  condition  may  become 
.orse  and  end  fatally.  More  often  under  suitable  treatment  it  gradually 
passes  off  in  a  few  hours,  the  pulse  becoming  slower  and  more  full,  the  skin 
warm,  the  temperature  increases,  slight  fever  often  ensuing,  and  the  patient 

jid  can  take  interest  in  his  surroundings.  At  the  commence- 
ment of  recovery  vomiting  is  a  common  symptom.  The  muscular  prostra- 
tion gradually  passes  away  and  the  patient  is  restored  to  his  usual  vigour. 

(2)  In  syncope  the  signs  are  very  similar,  but  the  higher  cerebral  centres 
are  more  affected,  loss  o!  the  senses  being  common,  usually  preceded  by 
buzzing  in  the  ears,  and  loss  of  vision  (the  surroundings  appearing  black 


SYNCOPE,  SHOCK  AND  COLLAPSE  115 

to  the  patient).     Recovery  in  cases  of  syncope  is  also  more  rapid  unless 
it  should  prove  fatal. 

Pathology.  Taking  it  as  certain  that  a  diminished  blood-supply  to  the 
brain  is  the  main  factor  in  both  these  conditions  we  must  briefly  consider 
how  this  diminution  and  the  fall  of  blood  pressure,  which  leads  to  it,  are 
produced. 

There  are .  three  factors  chiefly  concerned  in  maintaining  the  blood 
pressure,  and  through  this  the  supply  of  blood  to  all  parts,  including  the 
important  basal  ganglia  of  the  brain  and  spinal  cord.  These  are  :  (1)  The 
pumping  action  of  the  heart ;  (2)  the  constricting  mechanism  of  the  smaller 
arteries,  and  (3)  the  presence  of  a  certain  volume  of  blood  to  be  driven 
through  the  latter  by  the  former.  Derangement  of  any  of  these  factors 
will  affect  the  blood  pressure  and  general  blood-supply.  The  well-known 
inhibition  of  the  frog's  heart  by  striking  the  stomach  is  an  instance  of  how 
the  blood  pressure  may  be  lowered  by  an  insult  which  acts  reflexly  upon 
the  heart,  and  probably  accounts  for  cases  of  sudden  death  in  man  after- 
blows  on  the  epigastrium,  and  for  the  immediate  collapse  produced  by  the 
"  solar  plexus  blow  "  in  boxing,  which  is  most  probably  due  to  vagus  inhibi- 
tion of  the  heart  resulting  from  stimulation  of  the  stomach,  where  it  is 
exposed  in  the  epigastrium  or  "  mark."  It  is  questionable  if  inhibition 
of  the  heart  produced  in  this  maimer  ever  lasts  for  any  considerable  time. 
Either  death  follows  quickly  or  tolerably  rapid  recovery.  This  kind  of 
shock  is  closely  allied  to  syncope  or  heart  failure,  which  also  appears  to  be 
due  to  cardiac  inhibition,  whether  caused  by  excitement  or  sudden,  sharp, 
afferent  impulses,  such  as  blows  to  sensitive  parts,  e.g.  testis,  crushes,  &c. 
It  is  more  than  probable  that  such  a  syncopal  condition  is  often  combined 
with  the  alteration  in  the  vaso-motor  mechanism,  which  is  the  cause  of 
the  more  lasting  shock  and  collapse  following  severe  injuries,  grave  surgical 
operations,  &c. 

With  regard  to  the  manner  in  which  the  blood  pressure  is  affected 
through  the  vaso-motor  mechanism,  Crile  found  that  moderate  afferent 
stimuli  (mild  trauma)  caused  a  rise  in  blood  pressure,  presumably  from 
vaso-constriction ;  repeated  and  severe  stimuli  (crushing  limbs,  &c.)  pro- 
duced a  fall  in  the  blood  pressure  ;  this  he  considered  was  due  to  vaso- 
dilatation, resulting  from  a  tiring  out  of  the  constrictor  centre  by  over 
stimulation,  and  that  the  blood  stagnated  in  the  splanchnic  vessels,  which 
should,  if  this  were  the  case,  be  dilated.  As  Malcolm  points  out,  there  is 
no  evidence  of  such  vaso-dilatation,  but  in  cases  of  severe  shock,  e.g. 
prolonged  abdominal  operations,  the  viscera  are  just  as  aneeniic  as  the 
other  tissues  and  show  no  signs  of  vaso-dilatation.  Malcolm's  view  seems 
a  more  correct  explanation  of  Crile's  facts.  He  considers  that  the  fall  of 
blood  pressure  is  partly  due  to  escape  of  the  fluid  elements  of  the  blood 
into  the  tissues,  and  partly  from  excessive  vaso-constriction,  which  passes 
from  the  smaller  to  the  larger  vessels  and  finally  affects  the  heart  itself, 
so  that  its  cavities  are  diminished  in  size,  and  at  each  beat  there  is  an  in- 
creasingly diminished  output  of  blood.     This  diminution  of  the  volume 


116 


A  TEXTBOOK  OF  SURGERI 


of  the  cardio-vascular  system,  and  the  diminished  amounl  of  blood,  account 
for  the  fall  of  blood  pressure.  Thai  general  vaso-constriction  does  take 
place  has  been  demonstrated  with  tin-  ophthalmoscope  in  the  retina,  where 
the  vessels  contract  under  the  influence  of  shock. 

Henderson  maintains  thai  a  deficient  amounl  of  carbonic  acid  in  the 
tissues  (a  condition  termed  "acapnia  ")  is  responsible  Eor  the  spasm  oJ  the 
whole  vaso-motor  and  cardiac  mechanism,  which  causes  a  diminution  of 
the  amount  of  fluid  in  the  circulation  and  diminished  output  from  the  heart 
with  each  l>cat.  Finally,  in  many  cases  of  shock  the  volume  of  blood  in 
the  circulation   is  also  diminished    by    bleeding,   which   accompanies   the 

operation  or  accident,  and  natur- 
ally increases  the  condition  of 
cerebral  anaemia. 

Treatment  of  Shock,  (a)  Pro- 
phylaxis.  The  prevention  of  shock- 
in  the  larger  operations  can  be  to 
a  considerable  extent  accomplished 
by  attention  to  the  following  points  : 
(I )  The  amount  of  fluid  pre- 
sent in  the  body  should  not  be 
excessively  diminished  by  violent 
purging  or  starvation  before  oper- 
ations. If  such  depletions  have 
keen  necessary,  or  the  strength 
has  been  reduced  by  vomiting, 
circulation  by  administration  of 
intravenously  (two  to  three  pints 
form  an  average  dose).  The  patient  should  be  kept  warm  by  heating 
the  operating  room  to  70  .  and  keeping  his  immediate  surroundings 
warm  by  using  a  heated  table  or  hot-water  bottles  placed  under  the  patient. 
During  such  operation  attempt  should  be  made  to  diminish  painful  afferent 
impulses  by  using  local  anaesthetics  which  block  the  afferent  nerves,  such  as 
infiltration  of  the  tissues  with  novocain  or  by  spinal  anaesthesia  and  other- 
plans  of  nerve-blocking.  (The  whole  principle  is  called  by  Crile  Anoci- 
association  or  defending  the  sensorium  from  severe  afferent  impulses  which 
are  one  of  the  main  causes  of  shock.)  Where  general  anaesthesia  is  u^rA 
ether  should  be  chosen,  it  possible,  rather  than  chloroform  as  being  less 
depressing. 

Where  shock  is  actually  present  treatment  varies  with  the  underlying 
cause. 

(1)  Where  the  condition  is  due  to  heart  failure,  i.e.  a  condition  of 
syncope,  the  indications  are  to  promote  cerebral  circulation  and  increase 
the  heart's  action.  The  first  point  is  achieved  by  laying  the  patient  flat 
and  raising  the  lower  limbs  and  pelvis  (during  operations  placing  the  patient 
in  an  exaggerated  Trendelenberg  position),  the  second  administering  cardiac 
stimulants,  Buch  as  oxygen,  hypodermics  of  ether  10 minims,  or  strychnine 


Fig.  37. 


Infusion  of  saline  solution  into  the 
median  basilic-  rein. 


more    fluid    should    be    added    to    the 
normal  saline  solution  per   rectum    or 


GENERAL  INTOXICATIONS  117 

THj-  grain,  stimulating  the  heart  reflexly  by  very  hot,  damp  cloths 
placed  on  the  prsecordium,  employing  artificial  respiration,  and  finally 
by  massaging  the  heart,  which  can  be  done  in  infants  through  their  soft 
thoracic  wall,  but  in  adults  after  opening  the  abdomen  and  squeezing 
the  organ  through  the  diaphragm.  In  slighter  cases  of  faintness  a  dose  of 
sal  volatile  and  spirit  of  ether,  half  a  dram  of  each  in  water,  will  suffice  to 
revive  the  failing  patient. 

(2)  In  the  type  due  to  falling  blood  pressure  of  vaso-motor  origin  the 
main  indication  is  to  increase  the  amount  of  fluid  in  the  vessels,  especially 
in  the  cerebral  vessels.  The  patient  should  be  placed  in  the  inverted 
position,  the  limbs  bandaged,  and  the  abdomen  compressed  by  a  firm 
binder  ;  this  will  increase  the  flow  of  blood  to  the  brain.  The  amount  of 
circulating  fluid  is  increased  by  infusing  saline  solution  into  the  rectum  or 
subcutaneously  in  the  less  severe  cases,  but  where  the  condition  is  urgent 
intravenous  infusion  should  be  at  once  adopted,  since  the  result  of  this 
plan  is  far  more  rapid.  It  is  questionable  whether  suprarenal  extract  should 
be  added  to  the  infusion,  since  it  will  increase  the  vaso-constriction,  which, 
as  has  been  pointed  out,  may  be  the  cause  of  the  trouble.  Certainly  in 
practice  there  seems  little  advantage  in  saline  containing  suprarenal  extract 
over  plain  saline.  In  no  case  should  suprarenal  extract  be  added  if 
the  infusion  is  subcutaneous,  or  the  local  vaso-constriction  produced  may 
lead  to  ansemia,  necrosis,  and  gangrene.  Where  the  patient  is  conscious 
and  not  vomiting,  warm  liquids  by  mouth  are  to  be  given  freely.  Of  drugs 
morphia  should  be  given  in  practically  all  cases  of  shock  in  full  doses  \  to 
\  grain,  especially  in  accident  cases,  severe  abdominal  crises  (after  it  has 
been  definitely  decided  to  operate,  never  before  a  working  diagnosis  has 
been  made  or  symptoms  will  be  masked),  or  after  operations.  The  effect 
of  morphia  by  diminishing  the  sensibility  of  the  higher  sensorium  as  well 
as  by  its  action  as  a  cardiac  stimulant  is  most  beneficial  in  such  cases. 
Stimulants,  such  as  strychnine,  are  of  little  use  in  pure  vaso-motor  shock, 
as  (rile  has  shown  ;  but  as  shock  is  often  a  mixture  of  a  vaso-motor  with 
a  cardiac  depression,  the  use  of  strychnine,  ether,  ammonia,  &c,  is  not 
to  In-  regarded  as  entirely  out  of  court.  We  are  not  aware  of  any  attempt 
having  been  made  on  the  lines  suggested  by  the  work  of  Henderson  to 
improve  the  cardio-vascular  mechanism  by  increasing  the  tension  of  car- 
bonic acid  in  the  issues.  These  investigations,  however,  suggest  problems 
for  the  future. 

SURGICAL   ASPECTS   OF   GENERAL   INTOXICATIONS 

The  conditions  lien'  considered  are  such  intoxications  as  are  of  import- 
ance when  the  advisability  of  a  surgical  operation  is  contemplated.  Of 
these  the  more  important  are  alcoholic,  renal,  diabetic,  thyroid  intoxica- 
tions, and  the  toxsemic  condition  known  as  acidosis. 

Alcohol.  Some  of  the  possibilities  of  chronic  alcoholism  have  been 
intimated  in  the  section  on  Delirium  Tremens  ;  the  chance  of  a  fatal  outcome 
of  relatively  insignificant  operations  in  advanced  cases  of  such  poisoning 


U8  \  TEXTBOOK  OF  SURGERY 

renders  operation  in  alcoholic  subjects  inadvisable  unless  to  relieve  urgent 
conditions,  such  as  intestinal  obsl ruction,  strangulated  hernia,  01  compound 
fractures.  Where  operations  of  a  non-urgent  type  are  desirable  in  the 
Bubjecta  of  chronic  alcoholic  poisoning,  the  patienl  should  be  dieted  and 
kept  under  observation  for  some  little  while  beforehand,  to  attain  a  better 
general  condition  after  operation,  special  care  being  then  needed  to  mark'  the 
early  signs  of  delirium.  Moreover,  it  must  no1  be  forgotten  thai  alcoholics 
after  general  anaesthesia  are  especially  prone  to  lung  complications,  and 
that  they  are  for  this  reason  more  suitable  for  local  than  general  anaesthesia. 
.  \i.  Disease.  The  subject  of  renal  insufficiency  is  discussed  at 
more  length  in  the  section  on  Renal  Surgery,  and  also  the  importance  of 
deferring,  when  possible,  operations  on  the  urinary  system  till  renal  function 
is  at  its  best.  Operations  on  other  parts  when  renal  disease  is  present 
should  only  be  undertaken  after  some  consideration,  but  the  danger  varies 
greatly  with  the  type  of  renal  disease  present.  Thus  in  cases  of  granular 
kidney  with  mine  of  good  specific  gravity  and  quantity,  slight  traces  of 
albumen  and  a  few  casts,  and  no  obvious  signs  of  renal  inadequacy  (thirst. 
anorexia,  furred  tongue,  constipation,  and  torpor),  most  ordinary  operations 
may  be  undertaken  with  equanimity  ;  but  in  the  acute  or  subacute  condi- 
tions, due  to  large  white  or  large  red  kidneys  with  small  amount  of  urine, 
much  albumen  and  casts,  no  operation,  except  the  most  urgent,  should  be 
undertaken.     Since  in  these  cases  not  only  are  the  tissues  inclined  to  heal 

] rly,  but  the  upsetting  effect  of  an  operation  and  anaesthetic  may  hasten 

the  advent  of  uraemia. 

Diabetes  and  Glycosuria.  The  remarks  made  in  the  preceding  section 
hold  good  also  in  cases  of  diabetes,  but  in  these  cases  there  is  more  often 
urgent  need  of  operation,  owing  to  the  onset  of  gangrene.  With  modern 
aseptic  technique  the  risk  of  local  infection  of  the  wound  is  but  slight,  and 
such  patients  often  heal  quite  well.  A  more  imminent  danger  is  the  rapid 
onset  of  coma,  ending  in  death,  from  increase  in  the  poisons  (see  Acidosis) 
already  in  the  system  owing  to  the  shock  of  the  operation,  especially  if 
chloroform  be  used  as  an  anaesthetic.  Tn  such  cases  if  general  anesthesia 
i-  decided  upon,  nitrous  oxide  and  oxygen  should  be  used,  but  local  or  spinal 
anaesthesia  is  still  better. 

Acidosis,  Acetonurla,  Delayed  Chloroform  Poisoning.  This  is 
a  condition  of  toxaemia  found  in  diabetics  and  other  patients,  especially 
children,  who  have  been  starved  before  the  administration  of  a  general 
anaesthetic.  The  condition  is  apparently  due  to  a  deficient  amount  of 
carbohydrate  in  the  system,  and  an  upset  in  the.  carbohydrate  metabolism 
from  this  cause,  resulting  in  the  presence  of  acetone  and  diacetic  acid  in 
i  he  blood  and  tissues. 

The  condition  is  aggravated  by  the  adminisl  ration  of  general  anaesthetics, 

especially  chloroform.     The  signs,  which  do  not  come  on  for  some  hours 

(twelve  to  twenty-four)  after  the  anaesthetic,  are  urgent  vomiting,  collapse, 

small  rapid  pulse,  and  a  sweetish  odour  noticed  in  the  breath,  from  the 

ace  of  acetone.     Acetone  and  diacetic  acid  will  be  detected  in  the 


SOLID  ELEMENTS  OF  THE  BLOOD  119 

urine  in  small  amounts  ;  these  substances  are  often  present  (in  small  quan- 
tities) after  anaesthesia  without  producing  toxic  symptoms.  In  severe  cases 
the  collapse  passes  into  coma,  which  is  likely  to  prove  fatal. 

Treatment.  Before  operation  the  best  prophylactic  seems  to  be  glucose 
given  four-hourly  in  dram  doses.  After  anaesthesia,  the  administration 
of  sodium  bicarbonate  seems  to  be  more  efficacious  than  glucose,  and  this 
should  be  given  after  an  anaesthetic  if  the  above  signs  of  poisoning  appear. 
The  stomach  may  be  washed  out  with  2  per  cent,  bicarbonate  solution,  or 
this  may  be  injected  subcutaneously,  or  sodium  bicarbonate  may  be  given 
by  mouth  in  doses  of  1  to  2  drams  four-hourly.  The  possibility  of  such  an 
intoxication  points  to  the  need  of  careful  routine  examination  of  the  urine 
before  administration  of  a  general  anaesthetic,  and  if  sugar,  acetone,  or 
diacetic  acid  be  found,  administering  glucose  and  bicarbonate  of  sodium 
before  operation  and  bicarbonate  alone  afterwards  (Wallace  and  Gillespie)  ; 
or  better  still  using  local  anaesthesia  where  the  latter  is  a  feasible  method. 
Thyroid  and  pituitary  intoxications,  which  are  beginning  to  take  a 
recognized  place  in  surgery,  will  be  discussed  under  the  surgery  of  these 
organs. 

CHANGES   IN   THE   SOLID    ELEMENTS    OF  THE   BLOOD 

In  previous  sections  some  note  has  been  made  of  alterations  in  the  fluid 
constituents  of  the  blood,  as  described  under  intoxications  whether  (1)  exo- 
genous, e.g.  bacterial  toxaemias,  or  (2)  endogenous,  as  in  the  auto-intoxica- 
tions ;  it  remains  to  review  shortly  the  changes  in  the  formed  elements  of 
the  blood,  viz.  the  red  and  white  corpuscles.  Much  may  be  learned  in  many 
conditions  by  examination  of  the  blood,  though  more  in  cases  appertaining 
to  the  province  of  internal  medicine,  especially  of  tropical  medicine.  Still 
the  diagnosis  between  malaria  and  other  forms  of  intermittent  fever,  which 
may  be  of  a  surgical  nature,  e.g.  renal  suppuration,  can  be  greatly  assisted 
by  an  examination  of  the  blood.  The  formed  elements  of  the  blood  are 
examined  (a)  in  fresh  diluted  blood,  which  method  is  most  useful  for  determin- 
ing the  relative  numbers  of  the  various  elements  present  (blood  count), 
or  (b)  by  the  study  of  stained  specimens  which  is  of  service  in  determining 
the  relative  numbers  of  the  different  sorts  of  leucocytes  present  or  the 
presence  of  abnormal  constituents,  such  as  pathological  leucocytes,  e.g. 
myelocytes,  or  parasites,  such  as  those  of  malaria. 

The  appearances  of  blood  in  anaemia,  though  the  latter  is  common  in 
surgical  diseases,  demands  no  special  note.  Surgical  conditions  may  give 
rise  to  various  types  of  anaemia,  and  the  diagnosis  will  be  made  from  the 
local  condition  rather  than  from  examination  of  the  blood,  which  is  seldom 
of  much  help  except  in  studying  the  results  of  treatment,  in  increasing  the 
amount  of  red  corpuscles  or  haemoglobin. 

The  changes  of  the  leucocyte  content  of  the  blood  is  of  more  importance. 
For  a  description  of  the  various  forms  of  leucocytes  the  reader  is  referred 
to  works  on  clinical  pathology  ;  suffice  it  here  to  mention  that  the  following 
types  are  present :     (1)  The  "  polymorphonuclear "    cells    contain    fine 


[20 


\  TEXTBOOK  OF  SURGERY 


neutrophile  granules  and  an  irregular  nucleus,  and  normally  forms  7<>  per 
cent,  of  the  total  leucocytes.  (2)  The  eosinophile  cells,  which  form 
2  to  I  percent,  of  the  leucocytes  and  possess  granules  strongly  eosinophile 
and  much  coarser  m  texture  than  those  in  the  former  type.  (•">)  The 
lymphocytes,  which  are  present  to  the  amounl  oJ  25  per  cent,  and  arc  small 
round  cells  with  relatively  large  dark-staining  nucleus  and  little  eel]  body. 
The  larger  lymphocytes  and  mast-cells  (basophiles)  need  only  to  be 
mentioned.  Alteration  in  the  leucocyte  contenl  of  the  blood  is  usually 
both  relative  and  absolute,  i.e.  one  type  of  cell  will  be  largely  increased 

in  numbers,  the  others  re- 
maining little  affected.  Such 
increase  is  termed  a  leuco- 
cytosis of  the  type  of  cell 
in  question.  The  reverse  of 
this.  i.e.  a  diminution  of  any 
type  of  cell  is  railed  leuco- 
penia.  These  leukocytoses 
are  generally  the  result  of 
intoxications,  often  from 
bacterial  products.  In  most 
instances  such  increase  is  of 
the  polymorphonuclear  cells. 
1!  the  eosinophiles  are  in- 
creased the  condition  is 
termed  eosinophitia.  Where 
the  lymphocytes  are  in  ex- 
cess the  term  lymphocytosis 
is  applied,  and  if,  as  happens 
in  diseases  of  the  lymph 
glands  or  bone  marrow,  im- 
mature or  antecedent  forms 
of  leucocytes  are  present  in  the  blood,  derived  from  lymphnodes  or  marrow, 
the  term  leukcemia  is  used.  In  good  films  these  different  types  of  cell  can 
readily  be  distinguished  under  the  microscope,  and  their  relative  numbers 
counted. 

Polymorphonuclear  leucocytosis  is  met  with  in  many  infective  diseases. 
especially  when  these  are  of  suppurative  nature,  e.g.  in  lobar  pneumonia, 
erysipelas,  acute  peritonitis  or  acute  appendicitis,  leading  to  the  latter. 
The  leucocytes  are  normally  present  to  the  amount  of  8000  per  cubic  milli- 
metre :  if  increased  to  20,000  suppuration  is  to  be  expected  or  severe  inflam- 
mation, such  as  spreading  peritonitis.  In  practice  it  must  be  confessed 
that  a  blood-count  is  seldom  needed  to  disclose  the  presence  of  an  abscess, 
local  Bigns  usually  showing  the  need  for  exploration.  Still  in  the  less  urgent 
a  blood-count  may  help  in  the  formation  of  a  correct  diagnosis,  e.g.  when 
this  lies  between  deep-seated  suppuration  and  deep-seated  malignant 
growth.     In  severe  types  of  septicaemia,  leucocytosis  may  be  absent.     This 


Fig.  38.     Cellular  elements  of  the  blood  (magnified). 
A.  Large  mononuclear  leucocyte.    B,  Polymorphonu- 
clear co-inophile.     C,  Polymorphonuclear  neutrophile. 
D,  Lymphocyte. 


SOLID  ELEMENTS  OF  THE  BLOOD  121 

is  also  the  case  with  enteric  fever,  tuberculosis  (unless  secondary  pyogenic 
infection  has  occurred),  and  in  malaria. 

Eosinophilia  is  seldom  of  great  amount  and  is  found  in  hydatid  disease, 
but  also  in  some  chronic  skin  diseases  and  asthma. 

Lymphocytosis  apart  from  leukaemia,  in  which  the  lymphocytes  are 
abnormal,  seldom  occurs  to  any  great  extent,  but  is  found  in  typhoid  fever, 
tuberculosis,  and  malaria. 

The  recognition  of  abnormal  leucocytes  (myelocytes  of  various  sorts, 
aberrant  types  of  lymphocytes,  &c,  found  in  the  leukaemias)  is  important 
in  the  correct  diagnosis  of  various  forms  of  glandular  enlargement  or  splenic 
tumour.  Examination  of  the  blood  will  lead  to  the  discovery  of  the  causal 
agent  in  the  case  of  malaria,  nlariasis,  &c.  Bacteria  may  be  discovered 
by  cultural  methods,  and  this  plan  may  prove  of  service  not  only  in  diagnosis 
but  also  by  helping  to  provide  means  of  treatment  in  the  form  of  vaccines. 


CHAPTER  VIII 
GENERAL   SURGERY    OF   INJURIES 

M'  •  banical  Injuries  :  Bruising  :  Eaematoma  :  Hematocele  :  Wounds  :  Varieties 

and  Treatment  of  Wounds  :  Effects  of  Heat  and  Cold  :  Burns:  Frostbite: 

Corrosive  Fluids  :  Electrical  Discharges  :  X-rays  :  Thermic  Fever. 

Under  this  heading  will  be  considered  macroscopic  trauma  of  various  soils. 
which  may  be  classified  according  to  their  cause,  as  mechanical,  thermal, 
electrical,  and  corrosive. 

Mechanical  injuries  may  be  :  (1)  Closed,  i.e.  without  breach  of  the  skin  ; 
(2)  open,  where  the  skin  is  broken,  usually  known  as  wounds. 

(1)  Closed  injuries  are  produced  by  falls,  crushes,  blows  with  blunt 
objects,  &c,  and  vary  greatly  in  their  severity  from  slight  superficial  bruises 
to  severe  pulping  of  the  limbs  or  body,  with  associated  injuries  to  bones, 
joints,  vessels,  viscera,  &c. 

Apart  from  such  major  lesions,  which  are  detailed  under  fractures,  disloca- 
tions, abdominal  injuries,  &c,  the  effect  of  injuries  is  spent  in  rapturing 
the  smaller  blood-vessels,  causing  (1)  an  outpouring  of  blood  under  the 
skin,  and  (2)  if  the  number  of  vessels  thus  torn  is  great  some  impairment 
of  the  tissues  supplied,  leading  to  necrosis  or  gangrene. 

(1)  Extravasation  of  blood  from  blunt  violence.  Where  the  amount 
is  small  it  is  described  as  an  "  ecchymosis  "or  bruise.  "Where  it  is  larger 
and  there  is  a  definite  mass  of  blood,  forming  a  local  tumour  or  swelling, 
such  a  mass  is  known  as  a  "hsematoma."  Where  such  effusion  of  blood  is 
into  some  natural  cavity,  e.g.  the  tunica  vaginalis  or  peritoneum,  the  swelling 
produced  is  known  as  a  "  haematocele." 

The  diagnosis  of  such  results  of  injury  is  usually  a  simple  matter.  The 
purple-black  colour  of  a  bruise,  altering  with  time  to  shades  of  green,  brown, 
and  yellow,  is  sufficiently  well  known  to  require  no  further  mention.  Where 
the  effusion  of  blood  is  of  greater  amount  and  deserves  the  name  of  hserna- 
toma,  it  will  be  found  as  fluid  swelling,  appearing  within  a  few  hours  of 
injury  and  without  great  pain  as  a  rule.  If  large  there  may  be  slight  fever 
for  the  first  two  or  three  days;  as  the  blood  chits  the  tumour  becomes 
firmer  and  Li  boggy  "  to  feel,  but  is  painless  unless  suppuration  is  taking 
place,  and  usually  is  absorbed  fairly  soon.  Suppuration  is  a  not  uncommon 
complication  of  hematomas,  the  infecting  organisms  attaining  entrance 
through  some  small  abrasion  of  the  skin  or  from  some  ulcerated  focus  else- 
where. In  such  cases  the  swelling  will  become  tender  and  signs  of  local  in- 
flammation arise,  heat,  redness,  and  later  oedema  and  waxy  appearance  of 

122 


SURGERY  OF  INJURIES  123 

the  skin,  while  fever  will  be  far  more  marked  than  before.  Hematoceles  are 
described  elsewhere  (see  Testis). 

(2)  The  effect  of  rupturing  many  small  blood-vessels,  as  by  crushes  and 
blows,  sometimes  has  the  effect  of  stripping  the  skin  off  the  subcutaneous 
tissues  and  tearing  the  vessels  going  to  the  skin,  although  not  removing 
it  altogether  and  without  causing  any  external  wound.  In  such  cases  if 
the  area  thus  stripped  is  wide  the  skin  being  deprived  of  its  blood- 
supply  will  slough,  and  after  the  slough  has  separated  there  will  remain 
a  granulating  ulcer,  more  or  less  infected  according  to  the  care  which  has 
been  exercised  in  maintaining  asepsis.  Such  cases  are  very  similar  in 
appearance,  after  separation  of  the  slough,  to  burns  where  the  whole  skin 
has  been  destroyed. 

Treatment.  Bruises  and  small  hematomas  may  be  left  alone  or  treated 
with  cooling  lotions  for  the  first  few  hours  to  diminish  bleeding  ;  and  later 
with  fomentations  to  promote  absorption  of  the  effused  blood.  If  such 
measures  are  adopted  with  large  hseniatomas  absorption  is  extremely  long 
and  tedious  ;  suppuration  may  occur,  or  much  fibrosis  in  and  about  the 
clot,  or  if  the  hematoma  is  under  the  periosteum  ossification  may  take 
place  with  formation  of  a  bony  tumour.  In  such  cases,  therefore,  it  is 
better  practice  to  render  the  skin  aseptic  and  make  a  small  incision  into 
the  hematoma,  turn  out  all  fluid  and  clotted  blood,  close  the  small  incision, 
and  bandage  firmly  over  plenty  of  gauze  and  wool ;  such  elastic  pressure 
will  prevent  reaccumulation  of  blood,  and  the  slow  healing  and  possible 
unpleasant  sequelae  completely  avoided.  Such  treatment  must,  of  course, 
be  strictly  aseptic. 

Where  suppuration  has  taken  place  the  abscess  is  opened,  the  pus  and 
clots  removed,  and  the  cavity  drained  for  three  to  four  days  with  a  rubber 
tube.  Where  there  is  evidence  of  stripping  of  skin,  as  shown  by  extensive 
bruising  and  an  anaemic  condition  of  the  skin,  preparations  should  be  made 
to  ensure  sloughing  taking  place  under  aseptic  conditions  ;  the  skill  should 
be  purified  with  2  per  cent,  iodine  in  spirit  and  covered  with  sterile  gauze 
and  plenty  of  sterile  wool,  lightly  bandaged  on  so  as  to  interfere  as  little 
as  possible  with  what  small  remains  of  blood-supply  are  present.  Such 
a  limb  should  be  elevated  and  kept  warm  with  warm  bottles.  Should 
sloughing  take  place  the  after-treatment  will  be  similar  to  that  for  ulcers 
and  burns,  including  antiseptic  or  stimulating  ointments  and  lotions,  or 
if  extensive,  skin-grafting. 

OPEN    INJURIES    OR   WOUNDS 

These  may  be  divided  into  :  A.  Incised  or  clean-cut  wounds. 
B.  Lacerated  wounds,  which  include  small  superficial  lacerations,  deep. 
open,  ragged  wounds,  punctured  wounds,  gunshot  wounds,  &c. 

A.  Incised  Wounds.  These  are  caused  by  sharp  objects,  such  as  knives, 
razors,  broken  glass,  and  caused  accidentally  or  on  purpose,  as  in  surgical 
operations  and  suicidal  attempts.  Incised  wounds  are  also  due  to  blunt 
violence  when  applied  over  a  superficial  bone  :   thus  a  blow  on  the  skull  with 


li'l  \    I  BXTBOOK  OF  SURGERY 

a  truncheon,  or  ;i  fall  od  the  forehead  on  the  pavement  may  cause  a  cleanly 
cut  wound. 

s  gns.  The  shape  of  such  wounds  is  thai  of  regular  lines  whether 
straight,  curved,  or  angled  ;  they  gape  widely  ;  the  edges  arc  not  bruised 
and  are  cleanly  cut  :    bleeding  is  usually  free. 

Treatment.  It  the  wound  lias  nor  been  made  under  aseptic  conditions. 
as  in  the  case  of  operation  wounds,  measures  Bhould  be  taken  to  render 
the  wound  and  its  surrounding  aseptic  as  soon  as  possible.  First  aid  consists 
in  covering  the  wound  with  sterile  dressings  or  something  of  approximately 
sterile  nature,  such  as  clean  recently  washed  linen.  The  simplest  plan  of 
sterilizing  a  wound  is  to  swab  it  over  freely  with  iodine  solution,  l'  per  cent, 
in  spirit.  This  plan  seems  to  be  just  as  efficacious  and  far  less  irritating 
than  the  older  plans  of  washing  with  soap  and  water,  followed  by  ether  to 
remove  the  soap,  biniodide  solution  in  spirit  to  render  the  part  sterile,  and 
dilute  biniodide  or  carbolic  to  remove  the  irritating  spirit  solution.  Having 
cleansed  the  wound,  bleeding-points  are  secured  (if  large  vessels  are  divided 
they  must  be  secured  before  commencing  the  aseptic  toilet)  with  catch 
forceps  and  twisted  or  tied,  and  the  depths  of  the  wound  are  investigated 
for  foreign  bodies,  such  as  glass,  or  division  of  tendons,  nerves,  muscles,  or 
other  important  structures  (which  are  sutured  as  described  in  the  surgery 
of  these  structures).  The  wound  is  then  closed,  as  described  in  the  section 
on  Operative  Technique,  usually  by  sutures,  and  if  the  wound  is  deep  it 
should  be  sutured  in  layers.  Finally,  where  asepsis  is  not  certain,  as  in 
accidental  wounds,  a  drainage  tube  should  be  inserted  for  twenty-four 
hours,  especially  if  the  injured  area  is  extensive;  and  a  sterile  dressing  is 
placed  over  the  wound  and  kept  in  position  by  bandage,  strapping,  collodion, 
&C.,  for  about  ten  days. 

The  after-treatment  is  expectant,  the  wound  being  left  covered  except 
to  remov  any  drainage  tube,  or  unless  pain  and  tenderness,  commencing 
after  twenty-four  hours,  together  with  pyrexia,  suggest  that  infection  has 
taken  place,  when  the  wound  should  be  dressed  and  inspected.  Then  if  it 
appears  that  suppuration  is  taking  place  (from  redness,  oedema,  dirty 
discharge)  some  stitches  are  removed,  the  wound  irrigated  with  peroxide  of 
hydrogen,  drainage  established,  and  a  moist  dressing  applied  till  the  infection 
has  subsided.  The  stitches  are  removed  in  from  live  to  ten  days  according 
to  the  situation. 

B.   Lacerated  Wounds.    These  may  be  large,  widely  opened  injuries 
or  punctured  wounds,  including  those  caused  by  the  impact  of  bullets. 
(a)  Large  open  lacerated  or  contused  wounds  may  be  caused  by  severe 

blunt  violence,  including  blows  with  blunt  weapons,  stones,  crushes  by 
machinery,  or  under  the  wheels  of  carts  and  locomotives:  in  military 
surgery  from  the  bursting  of  shells. 

Signs.  Such  wounds  are  irregular  in  shape,  the  skin  and  the  tissues 
being  torn  and  bruised.  The  skin  around  is  often  undermined,  and  dirt 
or  foreign  bodies  of  various  sorts  are  often  ground  into  the  tissues.  Bleeding 
ia  usually  slight  even  in  severe  injuries:    thus  a  boy  caught  his  leg  in  the 


SURGERY   OF^INJUKIES  125 

wheel  of  a  cab  ;  the  leg  with  the  lower  epiphysis  of  the  femur  was  torn  off 
completely,  dividing  the  popliteal  vessels,  yet  he  practically  lost  no  blood. 

Owing  to  the  bruising  of  the  tissues  and  the  damage  to  the  blood- 
vessels, sloughing  is  very  likely  to  take  place,  and  the  sloughs  provide 
a  ready  growing  place  for  organisms  which  may  be  infective,  and  in  this 
way  a  severe  spreading  infection,  which  may  assume  a  gangrenous  type, 
is  likely  to  ensue  in  such  cases.  In  addition  to  local  troubles  tl^e  severity 
of  such  lacerated  injuries  leads  to  their  being  often  associated  with  consider- 
able shock. 

Treatment.  Immediate  treatment  consists  in  covering  the  wound  with 
the  most  sterile  substance  procurable  at  the  moment  to  prevent  further 
risk  of  infection,  and  in  combating  the  shock,  if  this  is  marked,  as  is  usual 
with  severe  lacerated  wounds,  such  as  compound  fractures,  &c.  Morphia 
]  to  h  grain  should  be  given  immediately  in  severe  cases  before  commencing 
transport  of  the  patient ;  when  arrived  at  hospital  or  home  saline  infusions 
per  rectum  or  intravenously  may  be  needed.  Local  treatment  consists  in 
converting  such  wounds  as  far  as  possible  into  aseptic  wounds  and  removing 
any  likely  points  of  attack  for  micro-organisms.  The  surface  of  the  wound 
should  be  rendered  clean  with  solution  of  iodine  in  spirit ;  next  all  obviously 
dead  or  badly  lacerated  tissues  or  parts  hopelessly  ingrained  with  dirt 
should  be  systematically  cut  away  till  a  freely  bleeding  surface  is  present 
all  over  the  wound,  showing  that  the  tissues  are  well  supplied  with  blood. 
In  minor  cases  it  may  be  possible  to  close  such  wounds  with  sutures. 

In  more  severe  cases  it  will  often  be  impossible  to  do  more  than  draw 
the  wound  partially  together  and  pack  the  remainder  with  sterile  gauze, 
allowing  it  to  heal  by  granulation.  If  signs  of  infection  follow  the  wound 
must  be  opened  freely,  irrigated  with  hydrogen  peroxide  or  weak  carbolic 
lotion  (1  in  60),  immersed  in  warm  baths  containing  lysol  (20  minims  to 
the  pint),  and  dressed  with  boric  fomentations  or  gauze  wrung  out  of  weak 
biniodide  lotion  (1  in  5000).  In  more  severe  cases  free  incisions  around  the 
original  wound  may  be  needed  to  ensure  free  drainage,  or  even  amputation 
as  a  last  resource. 

Primary  amputation  is  indicated  in  some  cases  of  severe  lacerated  wounds, 
depending  on  the  extent  of  the  wound  and  the  vitality  of  the  patient. 
Amputation  is  more  urgent  in  old,  feeble  persons  than  the  young  and  robust ; 
in  the  latter  very  few  injuries  call  for  immediate  amputation  unless  surround- 
ing conditions  are  bad,  as  on  a  battlefield.  For  severe  lacerated  wounds 
primary  amputation  has  a  better  prospect  than  if  performed  after  a  few 
days,  when  infection  of  the  wound  has  occurred.  Hence  it  is  important 
to  decide  immediately  if  amputation  is  called  for. 

Amputation  is  certainly  needed  where  a  part  is  already  practically 
amputated  or  so  badly  pulped  that  recovery  is  impossible,  or  where  gangrene 
has  already  set  in,  or  where  there  is  severe  local  infection,  which  does  not 
subside  on  freely  incising  and  irrigating  the  part,  or  where  uncontrollable 
secondary  hsemorrhage  occurs  in  such  a  wound.  Another  class  of  case  where 
primary  amputation  is  the  wisest  course  is  where  there  is  severe  laceration 


L26  \  TEXTBOOK  OF  SURGER? 

and  stripping  of  the  tissues  of  the  fool  is  old  persons  with  compound 
fractures  involving  the  tarsal  joints.  Injuries  to  the  main  vessels  call  for 
suturing  of  these,  or  grafting  it  the  surgeon  is  able  to  perform  such  operations. 

Where  much  tissue  has  been  torn  away  the  result  of  cicatricial  healing 
of  such  wounds  will  often  be  great  deformity.  This  can  often  be  prevented 
by  timely  adjustment  of  cutaneous  tla j>s  to  fill  the  breach,  or  by  the  use 
•  •I'  skin-grafts  which  should  be  used  as  soon  as  the  wound  is  clean. 

(b)  Punctured  wounds  may  he  caused  by  falls  on  sharp  objects,  such  as 
-pikes,  stabs  with  knives,  cVc.  (Bullet  wounds  are  considered  in  the  next 
section.)  Such  wounds  may  he  linear,  rounded,  or  irregular  in  shape,  of 
small  outward  extent,  ami  seldom  bleeding  appreciably.  The  danger  of 
such  wounds  lies:  (1)  In  the  introduction  of  infective  material  into  the 
depths  of  the  wound  :  (2)  In  the  unnoticed  injury  which  may  happen  to 
important  structures,  such  as  the  intestine,  heart,  large  vessels,  brain.  &c. 

Treatment.  Patients  with  such  wounds  should  be  examined  with  tin- 
view  of  excluding  injury  to  main  vessels  and  nerves  (testing  the  pulses  below 
ami  the  sensation  or  motion),  and  inquiry  held  into  the  possibility  of  injury 
of  viscera  (examining  the  rectum,  passing  a  catheter  to  exclude  punctured 
wound  of  the  bladder  or  examining  the  abdomen  for  tenderness  and  rigidity 
which  would  suggest  a  perforated  viscus).  The  surroundings  of  the  wound 
ail-  rendered  aseptic  as  before,  and  if  there  is  the  least  chance  that  any 
important  structure  has  been  injured,  or  that  a  foreign  body  has  been  left 
in  the  tissues,  careful  exploration  should  be  made,  enlarging  the  wound 
and  tracing  the  injury  to  its  termination. 

Further  information  on  this  important  subject  will  be  found  in  discussing 
injuries  of  regions  and  organs.  Where  the  clinical  signs  point  to  some 
affection  of  important  viscera  the  appropriate  cavity  should  be  opened. 
e.g.  the  pericardium,  peritoneum,  or  skull.  There  is  far  less  danger  in  explor- 
ing such  injuries  under  aseptic  precautions  than  in  leaving  them  alone. 
After  exploration  and  removal  of  foreign  bodies  and  cleansing  the  deeper 
parts  of  the  wound,  the  latter  should  be  closed  carefully,  suturing  important 
structures  which  may  have  been  injured  ;  drainage  for  two  to  three  days 
is  advisable  in  most  of  such  wounds. 

C.  Gunshot  Wounds.  These  vary  in  appearance  and  treatment  with 
the  type  of  bullet  and  the  velocity  with  which  it  strikes  the  patient  as  well 
ae  the  part  involved  in  the  injury. 

(1)  Wounds  with  large  bullets  travelling  relatively  slowly,  as  from 
revolvers  or  the  older  types  of  rifle,  produce  a  small  punctured  wound  of 
entry,  but  at  the  point  of  emergence  there  is  a  large  lacerated  excavation  : 
or  the  bullet  may  remain  in  the  tissues.  The  wound  then  is  a  combination 
of  the  punctured  with  the  open  lacerated  variety,  and  if  bones  are  struck 
they  are  likely  to  be  extensively  shattered. 

Treatment  consist.-;  in  rendering  the  wound  and  its  surrounding  aseptic, 
and  usually  (in  civil  practice)  in  enlarging  the  wound  and  exploring,  especially 
if  the  wound  is  over  some  important  viscera,  as  the  brain,  abdomen,  &c, 
or  over  a  large  vessel  as  the  femoral  artery.    Successful  exploration  is  greatly 


SURGERY  OF  INJURIES  127 

assisted  by  having  radiograms  taken  of  the  part  in  two  planes,  or  otherwise 
locating  the  bullet.  The  main  object  of  such  exploration  is  to  suture  wounds 
in  important  viscera  ;  secondly,  to  render  the  path  of  the  projectile  aseptic, 
and  establish  drainage.  Removal  of  the  bullet  is  less  important,  but  should 
be  undertaken  in  most  instances.  Otherwise  treatment  is  as  for  other 
punctured  wounds. 

(2)  Wounds  from  the  bullets  of  modern  small-bore  high-velocity  rifles, 
such  as  the  Lee-Enfield  or  Mauser.  The  small,  hard  bullets  of  these  rifles 
have  great  penetrating  power,  and  if  traversing  soft  tissues  produce  little 
harm.  The  wound  of  entrance  and  exit  are  both  minute,  and  if  covered 
with  an  aseptic  dressing  will  heal  in  a  few  days  with  complete  recovery. 

Should  nerves  or  main  vessels  be  penetrated,  anaesthesia,  paralysis,  or 
traumatic  aneurysms  and  aneurysmal  varix  will  develop,  and  watch  must 
be  kept  for  such  contingencies,  when  the  wound  should  be  explored  and  the 
injured  part  sutured  in  a  suitable  manner  (see  Arteries  and  Nerves,  Injuries 
of).  Immediate  exploration  is  indicated  where  there  is  severe  subcutaneous 
bleeding. 

If  such  a  bullet  strikes  a  long  bone  the  effect  will  differ  according  as  the 
hard  shaft  or  the  cancellous  end  sustains  the  brunt  of  the  injury. 

A.  Where  the  shaft  is  struck  it  will  be  comminuted  for  a  considerable 
distance  around  the  bullet  hole,  and  the  fragments  may  be  driven  through 
the  skin,  forming  a  very  severe  lacerated  wound,  associated  with  a  compound 
fracture. 

Treatment,  (a)  Where  the  fragments  are  not  driven  through  the  skin, 
simply  rendering  the  skin  aseptic  and  covering  the  apertures  with  sterile 
dressing  will  often  suffice  to  convert  an  open  into  a  close  comminuted 
fracture,  which  can  be  dealt  with  later  by  operation  if  necessary. 

(b)  Where  the  fragments  are  driven  through  the  skin  the  only  resource 
is  to  open  more  wrdely,  remove  fragments,  and  drain  ;  in  such  cases  amputa- 
tion of  the  limb  at  the  nearest  field-hospital  will  often  be  the  best  course 
to  save  the  patient's  life. 

B.  Where  the  bullet  passes  through  the  cancellous  end  of  a  long  bone 
or  any  cancellous  bone  it  will  cause  far  less  local  damage,  simply  boring 
a  clean  hole  right  through,  and  the  wound  is  likely  to  heal  well  under  an 
aseptic  dressing. 

The  most  recent  "  pointed  "  bullets  have  a  great  tendency  to  turn 
over  and  proceed  base  first,  the  result  often  being  very  extensive  shattering 
of  any  sort  of  bone. 

Bullet  Wounds  of  the  Skull.  If  penetrating  one  side,  whether 
coming  right  through  or  not,  such  wound  should  be  treated  by  opening  the 
skull  at  the  point  of  entrance  and  removing  fragments  of  bone  and  clots, 
cleansing  the  tissue  and  draining.  It  should  be  noted  that  glancing  bullets 
which  do  not  penetrate  may  shatter  the  inner  table.  Hence  if  any  "signs 
of  compression  of  the  brain  are  present  after  a  bullet  wound,  which  does 
not  penetrate,  the  skull  should  be  trephined  at  the  point  of  impact.  Finally, 
where  a  bullet  is  lodged  inside  the  skull  some  attempt  should  be  made  to 


128  A  TEXTBOOK  OF  SURGERY 

remove  it.  I>ut  only  after  carefully  Localizing  by  means  of  radiograms  in 
two  planes,  and  a  careful  study  of  the  clinical  Bigns  when  these  are  presenl 
I  n juries  of  the  Skull). 

Bullet  Wounds  of  the  Abdomen,  ll  due  to  bullets  of  small-bore, 
high-velocity  rifles  the  best  plan  of  treatment  in  military  surgery  is  to  keep 
the  patient  under  morphia  and  starved  as  long  as  possible,  placing  an 
aseptic  dressing  over  the  wound.  Even  drinking  water  should  be  curtailed 
as  Ear  as  possible,  and  feeding  should  be  commenced  very  gradually.  II 
the  intestine  is  penetrated,  the  wound  is  very  small  and  readily  plugged 
by  the  extruded  mucosa,  and  is  sood  sealed  off  by  lymph  il  the  bowel  is 
kepi  at  rest.  The  favourable  outcome  of  many  of  these  cases  is  doubtless 
due  to  the  empty  state  of  the  intestine  at  the  time  the  wound  was  received. 
In  civil  practice,  w  here  conditions  lor  operating  are  more  favourable,  explora- 
tion is  indicated  in  practically  all  abdominal  wounds  caused  by  bullets, 
with  suture  or  excision  of  injured  parts  as  seems  most  feasible. 

The  recently  used  "pointed"  bullet  is  often  responsible  for  severe 
lacerations  of  abdominal  viscera,  hence  exploration  of  such  wounds  is 
advisable  wherever  surroundings  allow . 

Wounds  with  Shot-guns.  Where  the  discharge  was  very  close  to 
the  patient  a  charge  of  shot  produces  a  very  severe  lacerated  wound,  destroy- 
ing skin,  muscles,  fascia,  and  vessels  ;  when  the  distance  is  a  few  yards 
the  result  is  merely  a  number  of  small  punctured  wounds,  of  little  importance 
unless  some  important  structure  such  as  the  eye  lias  been  struck.  The 
treatment  of  the  more  severe  types  of  shot-gun  wounds  is  similar  to  thai 
of  lacerated  wounds,  generally  cleansing,  removing  dead  tissues,  and  as 
many  shot  as  possible.  In  wounds  from  more  scattered  discharge,  shot 
can  be  picked  out  when  they  cause  trouble. 

Foreign  Bodies  Embedded  ix  the  Tissues.  If  these  are  large  and 
ragged,  associated  with  lacerated  wounds,  they  should  be  removed  as  being 
likely  to  increase  infection  ;  if  small,  such  as  needles  or  shot,  and  situated 
deeply  amongst  important  structures  without  having  injured  the  latter. 
and  if  not  causing  infection  they  are  best  left  alone  unless  symptoms  develop. 
If  it  is  determined  to  remove  such  bodies  they  should  be  most  carefully 
located  with  the  fluoroscopic  screen.  In  some  cases  a  small  incision  may 
be  made,  and  a  pair  of  Spencer-Wells  forceps  pushed  bluntly  through  the 
soft  tissues  and  made  to  grasp  the  object  (this  is  best  with  needles)  under 
the  guidance  of  vision,  aided  by  the  fluoroscopic  screen,  and  having  secured 
the  object  it  is  easy  to  cut  along  the  guiding  forceps  and  come  down  on  the 
foreign  body.  Special  care  is  needed  in  removing  needles  from  the  region 
of  the  annular  ligament  of  the  wrist  or  the  ball  of  the  thumb. 

The  process  of  repair  of  wounds  is  described  in  the  section  on  Inflamma- 
tion, 


BURNS  129 

THERMAL   INJURIES    OR   THE  EFFECTS   OF   HEAT   AND   COLD 
Both  extremes  of  heat  and  cold  produce  changes  in  the  tissues  of  an 
irritative  nature,  and  if  very  severe  necrosis. 

A.  Burns  and  Scalds.  These  lesions  are  very  similar  except  that 
in  the  latter  case  the  heat  often  being  less  severe  the  tissues  are  not  killed 
to  such  a  depth.  Thus  while  in  scalds  the  destruction  seldom  passes  far 
into  the  dermis,  in  burns  the  damage  though  often  superficial  not  infrequently 
affects  the  whole  thickness  of  the  skin,  or  even  of  the  limb.  The  degree 
to  which  the  tissues  are  involved  depends  on  the  vehemence  of  the  heat 
applied  and  the  length  of  time  for  which  it  acts,  and  usually  differs  in  severity 
in  various  parts  of  the  lesion.  It  is  customary  to  divide  the  degree  of 
damage  inflicted  into  stages  as  follows,  the  conditions  being  known  as  burns 
of  the  following  degrees  : 

(1)  Simple  hyperaeinia  or  redness,  as  is  the  case  in  sunburn  of  moderate 
degree.  Sometimes  in  such  cases  there  is  some  oedema  of  the  skin,  lasting 
about  twenty-four  hours,  and  desquamation  followed  by  pigmentation 
(sunburn)  follows  commonly. 

(2)  Where  the  heat  is  more  severe  there  is  rapid  effusion  of  serum  into 
the  subcuticular  tissues,  i.e.  into  and  below  the  epidermis,  leading  to  the 
formation  of  vesicles  and  bullae,  or  blisters,  under  which  are  the  bare  papillae 
of  the  skin.  Such  a  condition  often  arises  from  scalds  and  is  very  painful, 
and  if  extensive  may  cause  severe  shock,  but  as  the  papillae  soon  acquire 
new  epidermis  the  resulting  depression  does  not  last  long. 

(3)  If  the  destruction  is  deeper  the  papillae  are  partially  destroyed,  and 
after  the  superficial  sloughs  separate,  carrying  with  them  the  upper  part 
of  the  papillae,  there  will  be  left  the  truncated  papillae  between  which  islands 
of  epithelium  remain,  which  are  soon  able  to  cover  the  surface  with  epithe- 
lium. This  degree  of  destruction  causes  the  greatest  pain,  and  if  extensive 
most  shock  and  depression  since,  there  are  many  nerve-endings  exposed  in 
the  partially  destroyed  papillae.  But  owing  to  the  persistence  of  the  islands 
of  epithelium,  if  the  patient  does  not  die  of  shock  the  surface  soon  "  skins 
over,"  and  though  there  is  a  general  slight  scarring  this  is  too  mild  to  cause 
appreciable  contracture.  Thus  in  all  the  degrees  described  hitherto,  there 
is  no  appreciable  contracture  of  scar-tissue ;  it  is  otherwise  in  the 
remaining  degrees. 

(4)  Here  the  whole  dermis  and  the  papillae  are  destroyed.  After 
the  sloughs  separate  there  remains  a  large  granulating  ulcer,  which 
heals  slowly  by  ingrowth  of  epidermis  from  the  edges,  and  if  large,  unless 
covered  with  skin-grafts,  will  cause  great  deformity  from  contracture  of 
the  scar- tissue. 

(5)  Further  degrees  are  described  in  which  the  muscles  to  a  varying 
depth  or  the  whole  limb  is  charred.  In  such  case  also  healing  by  granulation 
will  alone  be  possible. 

Superficial  burns  and  scalds  are  important  from  their  general  as  well 
as  their  local  effects,  and  the  wider  the  injury  the  more  serious  these  effects, 
i  9 


130  \  TEXTBOOK  OF  SURGERY 

Shock  is  very  aevere  in  widespread  burns,  even  if  only  of  the  severity 
described  in  stage  2,  or  still  more  in  stage  •">.  in  which  the  sensitive  nerve- 
endings  in  the  papillae  are  exposed  and  thus  irritated. 

\  Superficial  burn  of  more  than  half  the  body-surface  in  an  adull  or  more 
than  one-third  in  a  child  is  likely  to  be  fatal  from  shock  within  a  few  hours, 
and  the  shock  is  greater  when  the  lesion  is  on  the  thorax  or  abdomen  than 
when  involving  the  extremities.  Later  the  large  raw  area  affords  ready 
ingress  to  infective  organisms,  and  there  is  often  imminent  danger  of  septi- 
caemia, while  the  surrounding  oedema,  if  the  burn  is  in  the  neck,  may  lead 
to  oedema  of  the  glottis,  which  will  rapidly  prove  fatal  if  tracheotomy  be 
not  performed.  Still  later  the  ehief  trouble  is  with  the  deformities  arising 
from  the  conl  ractnre  of  scar-tissue,  in  burns  which  are  deeper  than  the  third 
degree. 

I'ii 'it an  nl.  The  first  indication  in  severe  burns  and  scalds  is  to  obviate 
the  grave  shock  by  administering  full  doses  of  morphia,  brandy,  and  saline 
infusions  per  rectum.  These  patients  should  be  kept  warm  with  plenty  of 
blankets  and  warm  bottles.  The  dressing  of  severe  burns  is  often  best  left 
for  a  few  hours  till  shock  has  to  some  degree  passed  off. 

Local  Treatment.  Numerous  methods  of  dressing  burns  and  scalds  are 
in  vogue.  If  the  lesion  is  superficial  {i.e.  of  degree  1  or  2)  some  soothing 
ointment,  such  as  zinc  oxide  or  boracic,  made  up  for  choice  with  lanoline, 
will  suffice. 

Where  vesicles  and  bullae  are  present  these  are  best  snipped  with  scissors, 
and  so  emptied,  and  the  surface  covered  with  gauze  wrung  out  of  a  saturated 
solution  of  picric  acid,  which  is  both  analgesic  and  antiseptic.  This  forms 
a  good  dressing  for  most  burns  if  applied  from  the  commencement  of  treat- 
ment. In  deeper  burns  of  considerable  area  some  attempt  must  be  made 
to  render  the  part  aseptic,  especially  if  the  case  comes  under  treatment 
after  various  messes,  such  as  ink,  have  been  superimposed  by  the  patient's 
friends.  But  severe  treatment  of  the  surface,  such  as  scrubbing  and  the 
use  of  mercurial  or  carbolic  antiseptic  lotions,  is  to  be  deprecated,  as  being 
likely  to  add  to  the  shock,  further  destroy  the  damaged  tissues,  and  possibly 
lead  to  general  poisoning  from  absorption.  Where  there  is  evidence  of 
considerable  destruction  of  the  surface  the  latter  should  he  rendered  sterile 
with  iodine  solution  2  per  cent.,  or  picric  acid,  and  covered  with  boric 
ointment  containing  L  5  minims  of  oil  of  eucalyptus  to  the  ounce.  Eucalyptus 
renders  the  ointment  mildly  antiseptic  and  more  fluid,  and  therefore  easier 
of  removal,  which  will  usually  be  needed  as  sepsis  is  practically  impossible 
to  avoid  in  the  deeper  degrees  of  burns,  and  changing  of  dressing  is  essential 
to  avoid  retention  of  secretions.  Attempts  to  render  the  surface  sterile  and 
close  with  a  dry  sterile  dressing  are  not  satisfactory  in  widespread  burns.  After 
the  sloughs  separate  various  dressings  will  be  needed.  Fomentations  may 
assist  in  promoting  the  separation  of  sloughs,  but  tend  to  increase  the  size 
of  granulations  which  bleed  readily.     In  such  cases  the  eucalyptus  ointment 

ood.  Red  lotion  may  be  employed  to  keep  unruly  granulations  to  a 
proper  size,  and  scarlet  ointment  will  promote  the  growth  of  epidermis 


FROSTBITE  131 

from  the  edge  as  in  other  granulating  wounds.  Where  it  is  clear  that  a 
large  area  is  quite  bare  of  epidermis  and  there  are  no  small  islands  of  epithe- 
lium remaining,  to  initiate  new  growth  of  cuticle,  skin-grafting  should  be 
done  as  soon  as  the  surface  is  clean,  i.e.  in  three  to  four  weeks. 

In  very  severe  deep  burns  amputation  may  be  the  only  resource. 

The  first  few  dressings  of  widespread  burns  should  be  done  under 
anaesthesia,  especially  in  children. 

The  later  effects  of  burns  in  the  shape  of  deformities,  such  as  flexion  of 
the  elbow  or  a  fixing  of  the  arm  to  the  side  after  burns  of  the  axilla,  are 
treated  by  dividing  the  "  web  "  and  transplanting  a  suitable  pedunculated 
flap  from  the  neighbourhood  into  the  gap  thus  formed,  finally  skin  grafting 
any  remaining  raw  surface. 

B.  Injuries  from  Excessive  Cold  (Frost-bite,  Chilblain).  Cold 
produces  affections  of  varying  severity  consisting  of  inflammatory,  or  when 
more  severe,  necrotic  changes  in  the  part  in  question,  usually  the  extre- 
mities, especially  of  the  young,  the  aged,  the  ill-nourished,  or  those  much 
exposed  to  climatic  variations. 

Frost-bite  is  the  result  of  freezing  of  the  nose  or  ear-tips,  in  worse  cases 
of  fingers,  toes,  hands,  or  feet.  The  affected  part  becomes  white,  anaemic, 
insensitive,  later  hard-frozen  and  brittle.  If  the  process  has  advanced  too 
far,  or  if  the  process  of  "  thawing  out  "  is  done  too  rapidly,  there  is  a  severe 
reaction  on  the  part  of  the  tissues,  congestion,  hyperemia,  thrombosis, 
followed  by  gangrene  of  the  dry  type,  resulting  in  the  loss  of  a  varying 
portion  of  the  extremity.  The  damage  appears  to  be  due  to  the  crystallizing 
of  the  blood  and  lymph  in  the  process  of  freezing  and  thawing,  causing  the 
vessels  to  rupture,  leading  to  thrombosis  and  anaemic  necrosis. 

Treatment.  It  is  important  to  recognize  that  the  process  of  freezing  is 
not  very  painful  and  may  not  be  noted  by  the  patient,  whose  white  nose 
or  ear-tip  is  often  first  observed  by  some  other  person.  The  usual  treatment 
consists  in  vigorous  rubbing  with  snow  till  circulation  is  restored.  In  more 
severe  cases  the  frozen  part  must  be  "  thawed  out  "  very  slowly,  the  patient 
being  kept  in  an  ice-cold  room  and  the  part  bathed  with  iced  water,  made 
wa  imer  very  slowly.  Warm  drink  is  given  very  sparingly.  When  the 
circulation  is  restored  the  part  should  be  kept  warm  and  under  •  sterile 
dressing  (the  skin  being  first  sterilized),  so  that  if  gangrene  sets  in  it  will 
be  of  the  aseptic  variety.  Should  gangrene  ensue  in  most  cases  we  may 
wait  tor  a  line  of  demarcation,  and  if  the  part  is  large  amputate  close  above 
this  ;  if  only  a  small  fragment  is  dead  it  may  be  allowed  to  separate  natu- 
rally. Frost-bite  is  not  common  in  this  country,  but  may  occur  in  persons 
w  hose  tissues  and  circulation  are  poor,  from  moderate  degrees  of  cold.  Thus 
we  have  seen  gangrene  of  the  fingers  arising  in  a  diabetic  whose  work  rendered 
the  fingers  cold  for  long  periods.  Such  a  case  is  a  combination  of  diabetic 
gangrene  with  that  due  to  cold. 

Chilblain  (Pernio).  This  condition  arises  from  frequent  and  inter- 
mittent exposure  to  minor  degrees  of  cold,  especially  in  ill-nourished  children, 
and  usually  affects  the  fingers  and  toes,  which  become  hypersemic  and  itch 


i:;_>  \  TEXTBOOK  OF  SURGERY 

consumedly  in  fche  evenings  :    not  infrequently  fche  reddened  pari  breaks 
down,  forming  superficial  ulcers  which  heal  slowly. 

Treatment.  The  main  thing  is  to  promote  the  circulation  by  good  food, 
cod-liver  oil,  warm  clothes,  wool  socks  and  gloves,  ami  frequent  movemenl  : 
skipping,  dancing,  ami  other  regular  exercise.  Painting  with  menthol 
ointment  (2  per  cent.)  will  relieve  the  itching,  and  tincture  of  iodine  will 
promote  healing  of  ulcers. 

INJURIES   FROM   CORROSIVE   FLUIDS 

The  effect  of  these  is  very  similar  to  that  of  excessive  heat :  superficial 
gangrene  of  varying  depth  and  extent  results,  ami  the  treatment  is  as  for 
other  bums,  hut  the  noxious  substance  should  be  first  neutralized  if  acid 
with  application  of  chalk  or  magnesia,  if  an  alkali  with  weak  vinegar  : 
cither  of  which  neutralizing  agents  should  he  washed  oil'  before  applying 
the  antiseptic  and  soothing  dressing. 

I  larbolic  acid  is  the  most  insidious  "type  of  such  corrosive  fluids,  especially 
in  weak  solutions,  owing  to  its  great  penetrating  powers.  Thus  a  compress 
of  1  in  60  carbolic  applied  to  a  finger  for  some  hours  has  often  produced 
gangrene  of  the  whole  part  enveloped.     This  applies  particularly  to  small 

bs  such  as  fingers.  Nurses  and  others  entrusted  with  first-aid  treat- 
ment should  be  fully  informed  of  the  danger  arising  from  the  penetrating 
] lower  of  carbolic  :  we  have  known  a  nurse  lose  her  own  finger  from  under- 
estimating the  lethal  power  of  the  carbolic  compress. 

INJURIES  FROM   ELECTRICAL  DISCHARGES 

Under  this  heading  are  included  the  effect  of  lightning-stroke  and  of 
high-tension  apparatus,  such  as  live-wires,  live-rails,  &c.  ;  the  results  of 
such  electric  discharge  are  twofold,  general  and  local. 

(1)  The  general  effect  is  to  produce  actual  or  apparent  death  from 
syncope  of  cardiac  and  respiratory  origin.  It  is  important  to  recognize 
that  persons  struck  down  by  electric  discharge  and  to  all  intents  and  purposes 
dead,  can  fairly  often  be  brought  to  life  again  by  the  use  of  stimulants. 
such  as  hypodermic  injection  of  ether  and  prolonged  artificial  respiration. 
In  such  cases  artificial  respiration  should  be  steadily  persevered  with  for 
at  least  an  hour  before  giving  the  patient  up,  and  this  should  be  carried 
mi  longer  if  there  is  any  sign  whatever  of  return  of  life. 

(2)  The  local  effects  resemble  those  of  other  hot  or  caustic  materials 
varying  greatly  in  size  and  depth,  but  are  particularly  prone  to  delayed 
healing.     Treatment  is  on  similar  lines. 

BURNS   FROM  X-RAYS 

These  are  seen  occasionally  from  over-long  exposure  in  the  curative  use 
of  the  rays,  but  the  prolonged  intractable  eczema  ending  in  warts  and 
epitheliomatous  growths,  which  proved  fatal  to  some  of  the  pioneers  of  the 
art.  are  to-day  hardly  known,  since  X-ray  operators  protect  themselves 
and  the  rest   of  their  patients  with  screens  opaque  to  the  rays.     Ulcers 


SUN-  AND  HEAT-STROKE  133 

resulting  from  excessive  exposure  to  the  rays  are  slow  in  healing,  but  are 
to  be  treated  on  the  line  of  ulcers  from  other  cause. 

SUNSTROKE   OR  THERMIC  FEVER 

This  is  due  to  hard  work,  when  exposed  to  the  sun's  rays.  Alcohol 
plays  some  part  in  a  good  many  cases.  The  patient  may  simply  feel  faint 
and  ill,  or  may  fall  suddenly  comatose  and  die  rapidly.  More  often  he  is 
affected  with  severe  headache,  giddiness,  nausea,  and  vomiting  ;  coma  may 
follow  associated  with  a  full  rapid  pulse  and  high  fever,  even  hyperpyrexia 
(as  much  as  110°  is  recorded)  ;  convulsions  and  Cheyne-Stokes  respiration 
usher  in  the  end.  Thermic  ftvsr  is  to  be  distinguished  from  heat-exhaustion 
which  follows  hard  work  in  great  heat,  but  out  of  the  sun.  In  such  cases 
the  patient  collapses  with  subnormal  temperature,  cold  surface,  pinched 
face,  and  small,  weak  pulse. 

Treatment.  In  thermic  fever  the  ice-pack  or  iced-baths  are  advised 
for  the  hyperpyrexia,  chloroform  for  convulsions  ;  if  heart-failure  is  obvious 
infusions  of  saline  and  ether  subcutaneously.  Prophylaxis  is  perhaps  even 
more  important  in  the  form  of  adequate  covering  for  the  head,  such  as 
double  helmets  lined  with  red  cloth,  to  obstruct  the  more  injurious  of  the 
solar  rays. 

In  the  collapse  of  heat-exhaustion  stimulants,  such  as  brandy,  ether, 
and  ammonium  carbonate,  with  saline  infusions  into  rectum  or  veins,  are 
indicated. 


CHAPTER  IX 

GENERAL   PRINCIPLES  OF   SURGICAL   TECHNIQUE 

Anaesthesia  :  General  Anaesthesia  :  Varietii  -  :  Insufflation  Anaesthesia  :  Guides 
in  Anaesthesia  :  Dangers  :  Local  Anaesthesia  :  Nerve  blocking  :  Spinal  Anaes- 
thesia :  Choice  of  Anaesthetic  :  Asepsis  and  Antisepsis  :  Sterilization  :  Anti- 
septics (Chemical)  :  Preparations  for  Operation  :  The  Room, the  Patient,  the 
Surgeon  and  Assistants  :  Materials  used  for  Operations  :  Ligatures  :  Dressings  : 
Iik  isinns  :  Suturing  the  skin  and  deeper  parts  :  Drainage  :  After-treatment. 

ANESTHESIA,   ASEPSIS  ;   SUTURING  ;   AFTER  TREATMENT 

The  methods  of  therapy  are  extensive  and  various,  and  although  all  varieties 
may  be  of  use  in  surgical  cases  those  regarded  as  especially  in  the  province 
of  the  surgeon  are  mechanical,  manipulative,  and  cutting  operations. 
Therapeutic  measures  may  be  divided  into  : 

Chemical  or  drug  therapy,  including  the  use  of  such  substances  as  calomel 
and  quinine,  or  the  products  of  vital  activity,  such  as  thyroid  extract  and 
bacterial  antitoxins  and  vaccines.  Such  drugs  may  be  administered  by 
mouth,  skin,  rectum,  or  by  injection  into  subcutaneous  tissues,  veins,  or 
muscles. 

Physical  measures,  including  climate,  heat  of  various  kinds,  water 
(balneological    treatment    and    hydrotherapy),    electric    currents,    gamma 

iav<.  &c. 

Mechanical,  such  as  manipulation  and  wrenching  to  reduce  deformities 
and  dislocations  :   massage  and  exercises. 

Examinations  with  special  instruments  through  normal  apertures,  such 
as  the  bronchoscope,  cystoscope.  Under  this  head  will  fall  operations  for 
removing  foreign  bodies  through  natural  apertures  of  the  body  as  in 
lithotrity,  and  removal  of  foreign  bodies  from  the  (esophagus  and  bronchi. 

Cutting  operations,  involving  skin,  vessels,  nerves,  bones,  viscera.  &c, 
and  of  varying  nature  as  exploratory,  reparative  and  reconstructive,  plastic 
and  orthopaedic,  or  radical  removal  of  diseased  parts. 

It  is  the  last  three  groups,  manipulations,  examinations,  and  cutting 
operations  which  are  to  be  considered  as  par  excellence  surgical,  although 
the  other  methods  play  do  small  part  in  treatment. 

The  underlying  principles  conducive  to  success  in  these  measures  are 
in  the  first  place  aseptic  technique,  in  order  that  no  infection  may  be  intro- 
duced into  the  patient's  system  by  the  surgeon  (this  beimr  the  cause  of 
the  relatively  poor  results  of  surgical  practice  before  the  work  of  Lister); 
and  secondly,  the  use  of  anaesthetics  which  render  such  measures  more 
agreeable  to  the  patient  and  to  a  considerable  degree  obviate  the  shock 

134 


GENERAL    ANAESTHESIA  L35 

which  is  likely  to  result  from  the  more  severe  surgical  operations.     The 
administration  of  anaesthetics  will  be  first  considered. 

ANESTHESIA 

Since  the  initial  work  of  Simpson  and  Morton  with  chloroform  and  ether 
some  sixty  years  ago,  the  science  and  art  of  anaesthesia  has  made  enormous 
strides  and  has  become  a  highly  specialized  branch  of  medical  art,  so  that 
from  lack  of  space  we  can  do  little  more  than  indicate  the  main  outlines  of 
its  practical  use.  Besides  rendering  operations  painless  and  diminishing 
shock,  anaesthesia  has  the  further  advantage  of  rendering  the  patient  relaxed 
so  that  surgical  measures  can  be  carried  out  more  readily  and  accurately. 
Anaesthesia  may  be  general  or  local.  In  the  former  case  the  patient  is 
rendered  completely  unconscious  ;  in  the  latter  the  nerves  of  the  tissues 
in  the  region  of  the  operation  are  rendered  insensitive,  i.e.  the  afferent 
impulses  from  the  field  of  operation  are  blocked  out. 

Genekal  Anaesthesia.  The  drugs  used  circulate  in  the  blood  and  act- 
on the  higher  cerebral  centres  inducing  a  state  of  coma,  while  the  respiratory 
and  lower  centres  continue  to  perform  their  normal  functions.  Beside  the 
original  and  well-established  plan  of  introducing  drugs,  such  as  ether  or 
chloroform,  by  the  air  passages,  use  has  been  made  of  intravenous  administra- 
tion (ether,  hedonal),  or  even  giving  anaesthetics  per  rectum  (ether).  At 
present  the  danger  of  intravenous  administration,  whether  of  ether  or 
hedonal,  is  too  great  to  admit  of  its  general  use,  though  this  is  legitimate 
in  the  hands  of  anaesthetic  experts  in  certain  cases  :  both  the  intravenous 
and  rectal  methods  have  the  advantage  that  in  operations  about  the  upper 
air-passages  the  anaesthetic  apparatus  is  out  of  the  way,  and  in  the  intra- 
venous method  the  amount  of  fluid  introduced  into  the  veins  helps  to 
counteract  shock  :  the  rectal  method  has  led  to  severe  sloughing,  and  is 
to  be  used  with  care  ;  recently  a  solution  of  two-thirds  ether  and  one-third 
olive  oil  has  proved  satisfactory  for  rectal  anaesthesia.  The  drugs  employed 
to  produce  general  anaesthesia  are  ether,  chloroform,  nitrous  oxide,  and  ethyl 
chloride  ;  the  use  of  the  two  former  drugs  may  often  be  advantageously  com- 
bined with  hypodermic  injections  of  morphia  \  grain,  and  atropin  tAtt  grain, 
especially  in  abdominal  cases. 

Preparation  of  Patients  for  a  General  Ancesthetic.  The  stomach  should 
always  be  empty  before  commencing  an  anaesthetic.  The  last  meal  should 
be  light  and  at  least  four  hours  before  the  administration.  If  operations 
are  done  early  in  the  morning,  say  9  A.M.,  no  meal  will  naturally  be  needed 
after  a  light  supper  the  night  before,  but  a  cup  of  beef-tea  may  be  taken 
about  7  a.m.  This  is  the  best  time  to  operate  when  it  can  be  managed.  A 
full  stomach  will  almost  certainly  lead  to  vomiting  during  anaesthesia,  and 
the  vomitus  may  be  inhaled  into  the  lung  with  fatal  result.  Hence  in 
emergency  operations  shortly  after  a  full  meal  the  stomach  should  be 
emptied  with  the  long  tube  :  a  similar  plan  is  sound  where  vomiting  is 
actually  in  progress  as  in  case  of  intestinal  obstruction.  When  the  patient 
is  feeble  a  pint  of  warm  saline  should  be  given  per  rectum  one  to  two  hours 


136  \  TEXTBOOK  OF  SURGERY 

before  anaesthesia  is  commenced.  Morphia  and  atropirj  should  be  given 
an  hour  before  operation.  Where  there  is  time  Eor  preparation  the  patienl 
should  be  on  lighl  diet  for  three  days  before  the  operation,  the  bowels  kept 
regular;    Bmoking  should  be  interdicted  or  reduced  to  a  minimum  three 

days  before  a  major  anaesthetic.  An  enema  in  non-urgent  cases  may  be 
given  with  advantage  lour  to  six  hours  before  the  operation.  Empty  bowels 
are  of  special  importance  in  abdominal  operations,  rendering  manipulations 

easier  and  therefore  safer,  but  in  emergency  eases  of  the  "  acute-abdomen  " 
type  enemas  are  best  avoided,  unless  for  diagnostic  purposes,  since  they 
increase  the  depression  :  purges  are,  of  course,  in  acute  cases  absolutely 
banned.  Just  before  commencing  to  induce  anaesthesia  the  Madder  should 
lie  emptied,  by  catheter  if  necessary;  the  neck  should  be  freed  from  any 
confinement,  and  any  false  or  loose  teeth  removed  or  they  may  be  inhaled 
and  cause  trouble.  Either  at  this  time  or  shortly  before,  the  heart  and  lungs 
should  be  examined  to  ascertain  whether  there  is  any  reason  why  a  general 
anaesthetic  should  not  be  given.  The  urine  will,  of  course,  be  tested  in  all 
cases  before  operation,  since  finding  albumen  or  sugar  or  a  very  low  specific 
gravity  may  render  operation  inexpedient,  or  may  lead  to  alteration  in  the 
choice  of  anaesthetic,  e.g.  nitrous  oxide  and  oxygen  rather  than  chloroform 
where  sugar  is  present  in  the  urine. 

Administration.  During  the  period  of  administration  the  anaesthetist 
keeps  a  careful  watch  on  the  pulse  and  respiration  of  the  patient.  The 
left  hand  which  holds  the  jaw  forward  can  readily  feel  the  facial,  temporal, 
or  coronary  pulse  with  one  or  more  fingers.  Each  respiration  should  be 
heard,  felt  with  the  ringer,  or  seen  by  keeping  an  eye  on  the  abdomen  or 
thorax.  If  a  careful  watch  be  kept  in  this  manner  alterations  of  the  pulse 
or  respiration  will  lead  the  anaesthetist  to  note  that  difficulties  are  coming 
before  they  are  pronounced,  and  take  measures  to  obviate  them  before  they 
are  urgent.  The  main  secret  of  successful  anaesthesia  is  to  preserve  a  good 
"  air  way,"  or  in  other  words  to  prevent  the  tongue  falling  back  and  blocking 
the  entrance  to  the  larynx.  This  can  generally  be  managed  by  turning 
the  head  to  one  side,  keeping  the  mouth  slightly  open  with  a  dental "  prop," 
subluxating  the  jaw  forward  and  keeping  it  in  this  position  by  a  constant 
but  moderate  traction  at  the  angle.  If  tliis  is  not  sufficient  the  tongue  may 
be  pulled  forward  by  a  stitch  through  its  substance  (not  by  tongue-forceps, 
which  simply  brutalises  the  mucous  membrane  and  causes  a  very  sore  tongue 
for  some  days)  ;  failing  this,  Hewitt's  air- way  (a  wide  tube  reaching  into 
the  upper  laryngeal  opening)  may  be  used. 

SPECIAL  ANESTHETICS 

NTlTROUS  Oxide  or  Laughing-Gas.  This  is  given  from  a  rubber  bag 
w  it  h  close-fitting  face-piece  attached,  till  the  patient  shows  signs  of  dyspnoea 
(deeper  respiration,  flushing  and  slight  bluencss  of  the  face),  when  a  breath 
of  air  is  given  after  every  few  breaths  of  pure  gas  till  the  patient  is  un- 
conscious, as  shown  by  loss  of  corneal  reflex  and  relaxation  of  the  muscles, 
in  some  cases  by  jad  it  at  ion,  though  this  latter  sign  is  rather  due  to  asphyxia 


ETHER.    CHLOROFORM  137 

than  anaesthesia.  Anaesthesia  with  nitrons  oxide  takes  about  five  minutes 
to  induce  and  lasts  a  half  to  one  minute.  If,  however,  breaths  of  air  be 
given  at  intervals  a  fairly  regular  anaesthesia  can  often  be  maintained  for 
some  little  while ;  but  anaesthesia  should  not  be  maintained  for  more  than 
ten  minutes  in  this  manner,  since  dilatation  of  the  heart  readily  occurs 
and  may  prove  dangerous.  Where  longer  anaesthesia  is  needed  gas  may 
be  given,  mixed  with  oxygen,  by  using  Hewitt's  apparatus,  when  tolerably 
deep  anaesthesia  can  be  kept  up  for  an  hour  or  more  with  safety. 

Ether.  This  is  certainly  the  safest  general  anaesthetic  for  common 
use,  but  is  contra-indicated  in  lung  disease  or  where  there  is  much  congest iun 
of  the  neck,  larynx,  &c,  as  being  likely  to  lead  to  respiratory  embarrassment. 
As  with  other  drugs  the  purest  possible  should  be  employed  or  irritation 
of  the  lungs  and  bronchi,  leading  to  pneumonia,  &c.}  may  follow.  For 
many  years  ether  was  given  from  closed  bags,  such  as  Clover's  or  Ormsby's 
apparatus,  breaths  of  air  being  given  at  intervals,  and  a  preliminary  dose 
of  nitrous  oxide  being  administered  to  avoid  the  unpleasant  taste  and 
feeling  of  suffocation.  These  methods  have  of  late  been  largely  superseded 
by  the  "  open  method,"  in  which  a  mask,  of  several  folds  of  gauze  on  a 
wire  cage,  made  to  fit  the  face  tightly  by  further  padding  around  with 
gauze  or  Gamgee  tissue,  is  kept  wet  by  constantly  pouring  a  thin  stream 
of  ether  upon  it.  The  induction  of  anaesthesia  by  this  plan  is  slow,  but 
regular  and  safe  :  where  there  is  difficulty  of  inducing  anaesthesia  by  "  open 
ether,"  or  where  greater  celerity  is  needed  (full  anaesthesia  takes  ten  to 
fifteen  minutes  to  produce  by  this  method),  it  may  be  preceded  by  chloro- 
form and  ether  mixed  in  the  proportion  of  ether  2  parts,  chloroform  1  part, 
usually  known  as  CE2,  and  this  is  sufficiently  safe  for  practical  purposes. 
When  the  patient  is  "  under,"  open  ether  alone  is  used  unless  there  is  great 
difficulty,  and  the  patient  comes  round  readily.  The  signs  of  full  anaesthesia, 
which  is  usually  preceded  by  a  stage  of  struggling,  spitting,  and  incoherent 
language,  varying  with  the  less  or  greater  skill  of  the  anaesthetist,  are 
regular  stertorous  breathing,  flushed  face,  abolition  or  diminution  of  the 
corneal  reflex,  flaccidity  of  muscles  and  absence  of  struggling  and  rigidity. 
The  corneal  reflex  may  often  be  present  in  anaesthesia  quite  deep  enough 
for  surgical  measures. 

Mixtures  of  Chloroform  and  Ether,  Chloroform  and  ether  in  the 
formula  mentioned  above  as  CE2  must  be  freshly  mixed  or  decomposition 
occurs,  causing  great  irritation.  Formerly  alcohol  was  added  to  the  mixture 
to  render  it  more  stable,  the  mixture  being  known  as  the  ACE  mixture, 
consisting  of  alcohol  1,  chloroform  2,  ether  3.  This  is  a  useful  mixture, 
but  the  simple  CE2  is  more  commonly  used.  CE2  or  ACE  are  given  on  semi- 
closed  inhalers,  such  as  Rendle's  mask.  The  signs  of  anaesthesia  are  as 
for  open  ether.  These  mixtures  are  suitable  for  old  persons  with  emphysema, 
or  where  open  ether  is  insufficient  to  produce  muscular  relaxation. 

Chloroform.  This  is  certainly  a  more  dangerous  anaesthetic  than  ether, 
if  pushed  strongly,  since,  although  in  most  cases  it  is  the  respiration  which 
ceases  before  the  heart,  there  are  a  certain  number  of  instances  where  the 


138  \  TEXTBOOK  OF  SURGERY 

heart  will  ceo.'  bo  beal  before  the  respiration  gives  out,  which  is  a  mosl 
dangerous  quandary  and  one  from  winch  it  may  be  difficull  to  resuscitate  the 
patients.  Moreover,  the  occurrence  of  "  delay.'. I  chloroform  poisoning  "  from 
acidosis  is  more  usual  alter  the  use  of  chloroform  than  when  ether  is  employed. 
Chloroform  has  the  advantage  of  being  less  Irritating  to  the  Lungs  and 
respiratory  mucosa  generally,  and  cans.-  less  congestion,  and  hence  is  of 
use  m  operations  where  .edema  of  the  glottis  is  likely,  where  the  Lungs  are 
affected,  as  in  phthisis,  and  in  cerebral  operations.  Chloroform  must  also 
be  employed  where  an  actual  cautery  is  being  used  in  the  vicinity  of  the 
anaesthetic,  or  the  inflammability  of  ether  may  lead  to  terrible  accidents. 

Chloroform  must  always  be  given  with  free  admission  of  air  cither  on 
an  open  mask,  such  as  Skinner's,  or  by  pumping  air  saturated  with  chloro- 
form vapour  into  the  upper  air-passages  by  means  of  a  Junker's  inhaler. 

Ethyl  Chloride.  This  produces  deep  anaesthesia  rapidly,  and  has 
been  used  a  good  deal  for  small  operations,  such  as  the  removal  of  tonsils 
and  adenoids.  Three  or  live  cubic  centimetres  are  given  from  a  closed  bag, 
and  this  must  be  removed  as  soon  as  anaesthesia  commences,  as  shown  by 
deeper  respiration  :  if  administered  till  deep  anaesthesia  is  full,  the  patient 
may  pass  rapidly  into  a  dangerous  condition  as  the  drug  acts  very  rapidly. 
On  account  of  its  danger  ethyl  chloride  should  only  be  used  by  professed 
anaesthetists,  and  many  of  these  consider  it  unsafe. 

INTRATRACHEAL,   INSUFFLATION  ANESTHESIA 

Besides  the  open  method  of  etherisation  there  is  another  plan  which  is 
coming  to  the  front  and  will  probably  hold  an  important  position  in  the 
uear  future  ;  this  is  by  intratracheal  insufflation  (Auer  and  Meltzer).  A 
firm-walled  celluloid  tube  of  about  two-thirds  the  calibre  of  the  glottis  is 
inserted  into  the  trachea.  Down  this  tube  air  containing  varying  propor- 
tions of  ether  vapour  is  constantly  pumped,  the  excess  escaping  alongside 
oi  the  intratracheal  tube.  The  pressure  of  the  air  in  the  lung  can  be  varied 
at  will  by  altering  the  rate  of  flow  of  the  mixture.  This  method  is  excellent 
for  intrathoracic  operations,  since  the  lungs  can  be  deflated  or  expanded 
at  will,  and  there  is  no  danger  of  pneumothorax  even  if  both  pleural  cavities 
an-  opened  at  once:  further,  the  upward  current  of  air  prevents  blood 
or  mucus  passing  down  the  trachea  into  the  lung.  The  method  is  indicated 
especially  in  operations  on  the  Lung  or  (esophagus,  and  probably  will  be 
found  useful  for  operations  about  the  month  as  an  alternative  to  performing 
a  laryngotomy  and  plugging  the  lower  part  of  the  pharynx. 

Guides  i\  General  Anaesthesia.  A  regular  stertorous  respiration 
is  the  best  indication  of  moderately  deep  anaesthesia.  As  has  been  mentioned 
the  corneal  reflex  may  be  present  although  abdominal  reflexes  are  absent, 
or  may  be  absent  while  some  particularly  sensitive  reflexes  are  not  abolished, 
as  those  of  the  rectum  or  stomach. 

'I  he  pupils  are  small  in  moderate  anaesthesia,  and  when  the  anaesthesia 
is  becoming  lighl  the  pupils  dilate  but  react  to  Light.  When  dilated  and 
insensitive  to  light  the  anaesthesia  has  been  pushed  too  Ear  and  should  be 


DANGERS  OF  ANESTHESIA  139 

tut  off  for  a  time.  Signs  of  light  anaesthesia  and  tendency  to  come  round 
and  vomit  are  then  :  (a)  large  pupils  reacting  to  light  ;  (6)  shallow  respira- 
tion, which  becomes  imperceptible  shortly  before  the  patient  vomits,  often 
associated  with  (c)  feeble  pulse  and  (d)  bad  colour  (pallor).  In  such  cases 
(e)  the  eyes  are  nearly  always  filled  with  tears  :  this  lacrimation  is  a 
tolerably  sure  sign  of  light  anaesthesia  and  may  help  when  there  is  doubt 
as  whether  to  give  or  withhold  the  anaesthetic.  When  in  doubt,  however, 
it  is  always  wisest  to  withhold  the  anaesthetic  and  await  results,  for  it  is 
better  that  a  patient  strain  and  vomit  than  that  anaesthesia  be  pushed  to 
a  dangerous  point. 

Signs  of  too  deep  anaesthesia  are  :  (a)  dilated  pupils,  which  do  not  react 
to  light ;  (b)  shallow  respiration,  which  may  cease,  and  (c)  later  (usually) 
failure  of  the  pulse.  In  such  case  the  eye  never  lacrimates  :  hence  a  dilated 
fixed  pupil  with  a  dry  eye  is  a  danger-signal,  and  no  more  anaesthetic  should 
be  given  for  awhile. 

Difficulties  and  Dangers  of  Anesthesia.  These  concern  the  heart 
and  respiration. 

Failure  of  respiration  is  usually  from  inefficiency  of  the  air-way.  and 
is  obvious  from  the  patient  trying  to  breathe,  but  no  air  passing.  The 
anaesthetist  should  be  on  the  watch  for  slight  obstruction  of  the  air-passages 
and  remedy  the  deficiency  before  the  condition  becomes  urgent.  The 
simpler  methods  of  maintaining  an  efficient  air-way  have  been  already 
described,  viz.  holding  the  jaw  forward  with  the  mouth  propped  open, 
traction  on  the  tongue  with  a  stitch,  or  the  use  of  Hewitt's  artificial  air- way. 
When  respiration  is  becoming  obstructed  and  these  methods  fail  the  mouth 
should  be  opened  with  a  gag  and  a  finger  inserted  to  explore  for  foreign 
bodies,  such  as  clots,  &c,  in  the  larynx,  and  if  after  this  has  been  done, 
and  with  artificial  respiration  no  air  passes,  the  only  resource  is  to  perform 
tracheotomy  and  remove  clots,  &c,  from  the  trachea  with  feathers  or  long 
forceps.  More  often  after  opening  the  mouth  and  noting  the  larynx  clear, 
it  will  be  found  that  the  air-way  is  free,  but  the  failure  is  of  the  respiratory 
centre.  In  such  cases  artificial  respiration  by  Sylvester's  method  should 
be  kept  up  till  normal  respiration  commences  again.  So  long  as  the  pulse 
is  good  no  further  treatment  is  needed,  though  the  respiration  may  be 
initiated  by  regular  intermittent  traction  on  the  tongue,  combined  with  the 
artificial  respiration. 

Where  the  failure  is  primarily  of  the  heart  the  condition  is  far  more 
grave  and  may  be  hopeless.  Hence  the  importance  of  noting  tin-  pulse 
as  well  as  the  respiration,  and  taking  measures  to  stimulate  the  heart  if  the 
pulse  fail,  by  the  use  of  strychnine,  oxygen,  and  saline  infusion.  Should 
the  heart  suddenly  stop  no  time  should  be  lost,  but  artificial  respiration  and 
tongue  traction  commenced  at  once,  and  stimulants  given  hypodermically. 
If  chloroform  be  the  anaesthetic,  ether  given  subcutaneously  is  the  most 
rapid  ;  oxygen  is  also  good.  Should  the  heart  remain  in  diastole  the  only 
resource  is  to  open  the  abdomen  and  massage  the  organ  through  the 
diaphragm,  and  to  be  effective  this  will  need  to  be  done  quickly. 


140  \  TEXTBOOK  OF  SURGERY 

In  mod  cases  where  there  is  Borne  failure  of  both  heart  and  respiration 
the  anaesthetic  should  be  stopped  and  respiration  stimulated  by  pressing 
at  intervals  on  the  lower  ribs,  allowing  them  to  spring  back  by  their  natural 
•  •'astir  recoil.  This  mild  form  of  artificial  respiration  will  put  right  the  less 
aggravated  cases  of  difficulty  under  anaesthesia  :  but  if  matters  do  uol 
improve  the  more  powerful  method  of  Sylvester  should  be  used  without 
much  delay,  covering  the  wound  with  a  sterile  dressing  in  the  meanwhile. 
In  all  eases  before  initiating  artificial  respiration  ear-'  should  be  taken  to 
make  certain  that  the  air-way  is  quite  clear. 

After-treatmenti  The  patient  is  placed  on  one  side  with  the  lace  turned 
well  over  the  same  way.  and  watched  till  vomiting  has  taken  place  and  the 
coughing  reflex  well  developed.  The  head  should  be  low,  and  care  taken 
that  vomited  matter  is  not  inhaled  into  the  lungs;  this  is  managed  by 
keeping  the  face  well  over  so  that  the  mouth  is  almost  downward,  allowing 
easy  egress  to  vomitus.  Treatment  is  directed  to  counteracting  shock,  if 
necessary.  Later  the  nausea  may  be  relieved  by  small  drinks  of  very  hot 
water  and  washing  the  mouth  out  with  alkaline  lotion.  Feeding  is  com- 
menced gradually,  four  to  twelve  hours  later,  commencing  with  liquids, 
and  increased  according  to  the  capacity  of  the  patient  and  the  variety  of 
operation  performed. 

Local  Anesthesia.  Much  of  the  advance  in  this  branch  is  due  to  the 
work  of  Bier.  Several  drugs  have  been  used  for  this  purpose  :  cocain 
is  the  oldest,  and  though  decidedly  toxic  still  holds  its  own  in  several  direc- 
tions. Novocain  and  stovain  are  excellent  and  can  be  strongly  recom- 
mended. Eucain,  tropocain,  and  a  mixture  of  urea  and  quinine  are 
also  well  spoken  of.     Local  anaesthesia  can  be  obtained  in  various  ways. 

(1)  By  local  application  to  mucous  surfaces  which  can  absorb  the 
drug. 

(2)  By  infiltration  of  a  dilute  solution  of  the  drug  into  the  operation  area. 

(3)  By  anaesthetizing  the  nerves  which  supply  the  area  of  operation 
(nerve-blocking). 

(4)  By  infiltration  into  the  veins. 

(1)  Local  application  is  confined  to  the  nose,  eye,  and  urethra.  Cocaine 
is  the  drug  most  generally  employed,  though  owing  to  its  toxicity  care 
must  be  taken  in  its  use.  For  intranasal  operation  a  mixture  of  10  per  cent. 
cocain  with  an  equal  quantity  of  adrenalin  solution  packed  into  the  organ 
on  gauze  strips  gives  good  anaesthesia  for  small  operations.  The  addition 
of  adrenalin,  besides  diminishing  the  bleeding,  also  limits  the  absorption 
of  the  toxic  cocain  owing  to  the  diminished  blood-supply  to  the  part.  In 
minor  operations  on  the  eyelids  and  conjunctiva  5  per  cent,  cocain  may 
be  employed.  In  the  urethra  4  per  cent,  novocain  acts  well  and  is  safer 
than  cocain  owing  to  the  toxic  action  of  the  latter.  Signs  of  cocain 
poisoning  are  pallor,  faintness,  and  syncope  from  cardiac  failure,  which 
is  treated  by  placing  the  patient  recumbenl  and  administering  spirit  of 
ether  and  sal  volatile. 

Freezing  locally  is  another  topical  method  of  producing  anaesthesia, 


SPINAL  ANAESTHESIA  111 

and  is  of  use  in  opening  abscesses  or  inserting  exploring  needles.     The  skin 
is  frozen  with  a  spray  of  ethyl  chloride. 

(2)  Anaesthesia  by  Local  Infiltration.  Various  dilute  solutions 
of  cocain  with  salts  have  been  employed  (Scheich),  but  novocain,  2  to  4 
per  cent.,  is  very  satisfactory  and  simpler,  and  can  be  sterilized  by  boiling. 
Novocain  seems  to  have  little  or  no  toxic  effect,  even  if  injected  in  consider- 
able quantities.  These  solutions  are  introduced  under  the  skin  with  a 
hypodermic  syringe  having  a  rather  large,  long  needle  :  the  injection  leaves 
a  weal.  After  the  skin  has  been  divided  along  this  weal,  the  deeper  structures 
if  sensitive  may  be  infiltrated  layer  by  layer,  and  so  divided.  Often  anaes- 
thesia of  the  skin  only  is  sufficient,  most  deeper  structures  being  almost 
insensitive.  By  repeated  infiltrations  in  this  manner  operations  of  consider- 
able magnitude  can  be  carried  out. 

(3)  Nerve  Blocking.  This  may  be  done  in  any  peripheral  nerve  or 
nerves  ;  when  the  whole  cauda  equina  is  anaesthetized  the  term  "  spinal 
anaesthesia  "  is  used. 

(a)  Blocking  of  individual  peripheral  nerves  may  be  achieved  by  injecting 
2  to  4  per  cent,  novocain  into  the  nerve  sheath,  e.g.  of  the  brachial  plexus, 
the  median  or  ulnar  nerves,  &c.  Some  practice  is  required  to  hit  off  a  nerve 
with  precision  :  if  the  anaesthetic  is  near  the  nerve  but  not  into  the  sheath, 
anaesthesia  will  take  an  hour  or  so  to  develop,  while  if  made  into  the  nerve 
(known  by  the  tingling  produced  over  the  area  supplied  by  the  nerve) 
anaesthesia  follows  in  a  few  minutes. 

This  plan  is  useful  in  operating  on  empyemas  :  if  novocain  is  injected 
above  and  below  the  rib  at  its  angle  the  anterior  portion  will  soon  become 
insensitive  and  can  be  removed  without  pain. 

(b)  Spinal  Anesthesia.  This  method  consists  in  injecting  an  anaesthetic 
into  the  spinal  theca  which  surrounds  the  cauda  equina,  and  producing 
"  nerve  blocking  "  of  all  these  nerves.  In  this  way  anaesthesia  can  be 
produced  for  all  parts  below  the  umbilicus,  and  in  a  certain  number  of  cases 
anaesthesia  will  be  present  up  to  the  costal  margin,  allowing  of  operations 
on  the  stomach,  gall-bladder,  &c.  A  great  feature  of  the  anaesthesia  obtained 
by  this  method  is  the  complete  relaxation  present,  very  useful  in  difficult 
pelvic  operations  :  moreover,  the  effect  of  stovain  is  to  cause  considerable 
intestinal  peristalsis,  which  is  of  sen-ice  in  cases  of  intestinal  obstruction. 
Various  drugs  are  employed,  such  as  novocain,  tropocain  :  we  have  found 
stovain  (Billon)  satisfactory.  This  is  made  up  with  normal  saline  solution  : 
but  stovain  and  dextrose  are  of  good  report  (Barker),  the  latter  owing  to  its 
greater  specific  gravity  will  travel  up  the  spinal  theca  if  the  patient  is  placed 
in  the  Trendelenberg  position,  and  therefore  in  such  cases  stovain  (Billon) 
is  to  be  preferred,  since  this  does  not  gravitate  with  the  patient's  position. 

The  needle  is  inserted  between  the  3  and  4  or  4  and  5  lumbar  spines. 
The  patient  lies  on  the  side  with  the  knees  and  head  pulled  together  in 
position  of  marked  kyphosis  to  open  out  the  laminae  behind.  The  back  is 
painted  with  iodine  solution,  and  the  position  of  the  iliac  crest  noted  which 
corresponds  to  the  fourth  lumbar  spine.     In  children  it  is  safer  to  go  in 


I  II'  A  TEXTBOOK  OF  SURGERY 

the  fourth  space.  I  be  needle,  which  should  be  of  nickel,  is  inserted  in  the 
middle  line  or  one-quarter  to  one  side  of  this  below  the  third  or  fourth  spine 
and  pushed  horizontally  forward  :  after  the  skin  is  pierced  it  will  be  fell 
to  penetrate  first  the  liga nieiit inn  suhllavuni  or  interspinous  ligament,  and 
then  the  tough  theca.  When  the  trocar  is  removed  cerebro-spinal  fluid 
will  tl<>\\  if  the  theca  is  properly  penetrated,  especially  if  the  patient  coughs. 
Some  practice  is  needed  to  reach  the  theca  with  precision  on  the  first  attempt . 
The  needle  should  be  boiled  in  water,  not  in  soda  solution,  as  the  latter  de- 
composes stovain.  The  syringe  containing  the  dose  of  anaesthetic  is  fixed 
to  the  cannula,  and  some  cerebro-spinal  fluid  allowed  to  mix  with  the  drug, 
and  then  tin1  mixture  of  cerebro-spinal  fluid  and  anaesthetic  forced  back 
into  the  theca.  the  syringe  withdrawn,  and  the  puncture  sealed  with  collodion. 
Unless  cerebro-spinal  fluid  Hows  from  the  cannula  it  is  little  use  injecting 


Fig.  39.     Lumbar  puncture,  showing  localization  of  third  Lumbar  spine  on  a  level 
with  t lit-:  iliac  crest,  and  the  position  of  the  patient. 

the  anaesthetic.  The  patient  is  then  turned  on  the  back,  and  the  paralysis 
of  the  lens  and  appearance  of  anaesthesia  tested  with  a  needle  as  it  spreads 
up  the  legs  and  abdomen.  When  successful  anaesthesia  should  reach  the 
umbilicus  about  five  minutes  after  injection.  The  amount  of  the  drug  to 
use  is  *6  to  *8  of  a  c.c.  of  10  per  cent,  stovain,  which  equals  6  to  <s 
centigrams  of  the  drug  :  of  tropocain  5  centigrams  are  used. 

In  addition  to  the  advantages  of  greater  relaxation,  and  increased 
intestinal  peristalsis,  shock  is  greatly  lessened  by  the  use  of  spinal  anaesthesia, 
from  the  inhibition  of  painful  afferenl  impulses.  Moreover,  there  is  no 
irritation  of  the  lungs  from  inhaling  anaesthetic  and  no  danger  of  inhaling 
vomited  material  (which  is  not  infrequently  the  immediate  cause  of  death 
in  cases  of  intestinal  obstruction  under  general  anaesthesia).  The  method 
is  also  useful  if  the  surgeon  is  short  of  assistants.  The  dangers  are  respira- 
tory paralysis,  usually  from  over-dose  or  inverting  the  patient  too  early 
if  there  is  dextrose  in  The  anaesthetic  solution  ;  meningitis  is  unlikely  with 
reasonable  aseptic  precautions;  severe  headache  has  been  recorded,  but 
is  not  at  all  common.     Occasionally  paralysis  of  the  legs  or  bladder  persists 


CHOICE  OF  ANAESTHETIC 


143 


for  a  while,  but  such  cases  are  rare  and  of  seldom  more  than  transient 
duration. 

(4)  Local  Infiltration  into  Veins.  In  this  method  the  veins  are 
filled  locally  with  a  dilute  solution  of  anaesthetic.  A  needle  is  placed  in  a 
vein  ;  the  limb  is  raised  to  empty  it  of  blood,  and  a  tourniquet  placed  above 
and  another  below  the  site  of  operation.  Then  through  the  needle  the 
vein  of  this  sequestrated  area  is  filled  with  dilute  anaesthetic,  e.g.  1  per 
cent,  novocain  (adrenalin  must  not  be  added  lest  the  great  vaso-constriction 
produce  gangrene).  This  method  produces  anaesthesia  of  a  large  block 
of  tissues  (between  the  tourniquets),  admitting  of  extensive  operations, 
such  as  excision  of  joints,  amputations.  Naturally,  it  is  only  suitable  for 
operations  on  the  extremities.     At  the  close  of  the  operation  the  tourniquet 


Fig.  40.     The  lumbar  vertebrae,  showing  where  a  needle  will  pass  in  lumbar  position. 


is  removed  slowly  so  that  the  escape  of  an  anaesthetic  into  the  circulation 
is  very  slow. 

Choice  of  Anesthetic.  Ether  given  by  the  open  method  is  the 
anaesthetic  of  choice  in  most  major  operations.  Contra-indications  are 
states  of  general  intoxication,  as  diabetes  and  uraemia,  and  lung  diseases  of 
any  degree  of  severity,  as  pneumonia,  bronchitis.  Where  severe  shock  is 
present  and  nerve  blocking  is  possible,  as  in  operations  below  the  umbilicus, 
such  as  intestinal  obstruction,  double  amputation,  &c,  spinal  anaesthesia 
is  on  the  whole  safer.  Chloroform  is  in  most  instances  decidedly  more 
dangerous  than  ether,  being  a  cardiac  depressant,  while  ether  is  a  stimulant, 
but  as  it  causes  less  congestion  it  is  advisable  where  disease  of  the  lung  is 
present,  or  where  oedema  of  the  glottis  is  likely  to  occur,  as  in  deep-seated 
inflammations  of  the  neck.  (In  these  conditions  local  anaesthesia  should 
be  employed  if  possible.)  Important  practical  advantages  of  chloroform 
are  its  greater  portability  and  less  volatility,  rendering  it  essential  in  military 
and  tropical  surgery. 

Local  anaesthesia  is  of  special  advantage  where  the  surgeon  is  single- 


Ill  A  TEXTBOOK  OF  SURGERY 

handed  or  requires  his  only  serviceable  assistant  for  a  difficult  operation. 

With  practice  many  major  operations,  such  as  amputal  rniotomy, 

my,  &c.,  can  1"'  done  under  local  or  intravenous  local  infiltration. 

Where  the  operation  is  below  the  umbilicus  and  of  any  magnitude,  spina] 

i>  preferable  to  local  anaesthesia,  especially  where  there  is  great  shock,  or 

where  complete  relaxation  is  essential,  as  in  operations  on  the  acute  abdomen. 

sion  of  the  rectum,  prostate,  and  amputation  at  the  hip-joint,  or  where 
contra-indicated  as  in  diabetic  gangrene,  though  here 
nitrous  oxide  with  oxygen  is  useful.  Nitrous  oxide  is  useful  for  short 
anaesthetics  for  dental  operations,  removing  nails,  tonsil-,  and  adenoids,  or 
opening  abscesses.  It  this  is  used  for  more  prolonged  anaesthesia  it  is 
always  best  to  combine  it  with  oxygen.  Nitrous  oxide  with  oxygen  may 
be  used  for  major  operations,  especially  if  combined  with  local  infiltration 
anaesthesia,  -   Jted  by  Crile  (anoci-association  anaesthesia),  though 

whether  this  somewhat  complicated  technique  is  really  superior  to  open 
ether  or  spinal  anaesthesia,  except  in  -pecial  case-,  is  by  no  means  certain. 
Finallv.  we  must  remind  the  reader  of  the  great  benefit  in  many  cases  of 
administering  a  hypnotic,  such  a-  morphia  (best  with  atropin),  before  giving 

neral  anaesthetic,  both  for  improving  the  condition  of  the  patient  at 
operation  and  rendering  the  period  of  recovery  less  troublesome  by  diminish- 
ing the  vomiting  and  secretion  of  mucus. 

GENERAL  OPERATIVE  TECHNIQUE 

In  this  section  Anil  be  considered,  first,  the  methods  whereby  operations 
may  be  conducted  under  aseptic  conditions,  and,  secondly,  the  general 
technique  requisite  in  cutting  operations,  such  as  opening  and  closing  the 
skin  and  tissues  generally. 

Antisepsis  and  Asepsis.  The  goal  in  view  is  to  make  openings  into 
the  body  or  to  investigate  parts  which  are  easily  infected.  e.g.  the  bladder, 
without  risk  of  introducing  micro-organisms  in  the  process,  since  such  micro- 
isms  may  be  of  infective  nature  ;  further,  to  render  wounds  and  other 
places  injured  free  from  such  organisms.  From  what  has  already  been 
I  it  will  be  appreciated  that  micro-organisms  are  everywhere  present  : 
fortunatelv  only  a  minimum  of  these  are  pathogenic.  The  latter  varieties 
are,  however,  especially  coi  1  in  the  abodes  of  men,  above  all  where 

disease  is  treated,  viz.  in  hospitals,  so  that  there  is  always  a  considerably 
ber  prospect  of  infections  arising  in  hospitals  (unless  careful  and  suitable 
technique  be  adopted)  than  where  operations  are  performed  in  the  depths 
of  the  country  :  this  being  the  reason  why  in  the  pre-antiseptic  days  surgical 
patients  in  hospitals  perished  in  hundreds  from  sepsis,  while  the  country 
practitioners  were  often  successful.  With  these  objects  in  view  it  is  necese 
to  prevent  the  presence  of  organisms,  or  in  other  words  to  destroy  them, 
whether,  when  occurring  in  the  vicinity  of  wounds,  they  come  from  the 
patient's  skin,  the  hands  of  the  surgeon  and  his  assistants,  or  from  dressings, 
ligatures,  instruments,  or  the  air.     (Bacteria  are  very  prevalent  in  air-borne 


ASEPSIS  145 

Attempts  have  been  made  to  draw  distinctions  between  anti-  and 
a-septic  methods,  and  much  unnecessary  verbiage  and  splitting  of  hairs  have 
ensued.  Asepsis  is  only  possible  by  the  action  of  antiseptics,  i.e.  wounds, 
fields  of  operation,  hands,  instruments,  &c,  are  made  barren  of  micro- 
organisms by  the  use  of  antiseptics  ;  for  it  is  only  reasonable  to  include 
heat  amongst  antiseptics  as  well  as  various  chemical  substances.  In  other 
words,  as  the  result  of  antiseptic  measures  we  attain  condition  of  asepsis, 
which  may  be  strict  in  the  bacteriological  sense,  but  in  many  instances  is 
only  a  modified  sepsis  ;  thus  complete  asepsis  is  seldom  or  never  attained 
on  mucous  surfaces. 

Asepsis  is  produced  by  the  action  of  heat  and  a  multitude  of  chemical 
substances,  which  are  of  use  under  different  circumstances.  Heat  is  the 
most  perfect  destroyer  of  microbes,  since  after  its  action  non-irritating 
substances  are  left,  but  this  method  is  obviously  unsuitable  for  the  sterilizing 
of  living  tissues  whether  of  the  patient  or  surgeon. 

Stekilization  by  Heat,  (a)  Dry  heat.  Heat,  such  as  a  flame  or 
heated  air,  is  seldom  used  in  surgical  procedure,  though  sterilizing  small 
objects,  such  as  wires,  in  a  flame,  is  a  useful  method  in  bacteriological  work. 
The  most  useful  methods  are  by  boiling  or  the  use  of  superheated  steam. 
(b)  Boiling  in  a  solution  of  2  per  cent,  washing  soda  in  water  for  ten  minutes 
is  a  simple  plan  and  serves  for  blunt  metal  instruments,  rubber  gloves, 
tubes,  silk  ligatures,  &c.  Towels  and  dressings,  linen,  &c,  may  also  be 
boiled  and  sterilized  in  an  emergency  ;  an  ordinary  fish-kettle  will  contain 
enough  for  a  large-sized  operation  in  a  cottage.  Xote,  tetanus  and  anthrax 
spores  survive  boiling  for  such  a  short  period,  but  these  organisms  are  so 
unlikely  to  be  fouling  instruments  that  unless  there  is  special  reason,  as 
after  operating  on  such  cases,  there  is  no  need  to  boil  instruments  for  the 
full  hour  needed  to  destroy  these  more  resistant  forms  of  life. 

(c)  Superheated  steam  under  pressure  is  a  rapid  and  serviceable  method 
of  producing  dry,  thoroughly  sterilized  dressings,  towels,  gowns,  &c,  and 
is  suitable  for  hospital  and  institution  work  ;  moreover,  such  dressings 
preserved  in  air-tight  tins  remain  sterile  indefinitely  and  are  convenient 
for  transport.  The  objects  to  be  sterilized  are  placed  in  a  strong  chamber 
or  "  autoclave,"  and  subjected  to  steam  at  H0°  C.  for  twenty  minutes. 
This  will  destroy  all  organisms  throughout  a  large  mass  of  material ;  by 
suitable  methods  of  cooling  the  sterilized  matters  are  obtained  quite  dry. 
the  whole  process  taking  an  hour. 

Chemical  Antiseptics  are  legion,  but  only  a  few  of  the  more  promiuent 
demand  notice.  Their  numbers  declare  their  relative  inefficiency,  for  the 
perfect  antiseptic,  which  is  fatal  to  all  microbes  and  quite  innocuous  to  the 
tissues,  remains  yet  to  be  discovered. 

Carbolic  acid  (phenol),  the  oldest  antiseptic,  was  employed  by  Lister 
in  his  memorable  labours,  and  is  still  valuable  in  certain  directions".  In 
the  almost  pure  state  (really  containing  a  slight  amount  of  water  to  render 
it  liquid)  it  forms  an  admirable  caustic  for  cleaning  sloughy,  infected  surfaces, 
as  carbuncles.  Dilute  solutions,  1  in  40  to  1  in  100,  are  useful  for  washing 
i  io 


1 16  \  TEXTBOOK  OF  SURGERY 

out  foul  cavities,  including  the  mouth;  Btrongei  solutions  are  useful  for 
disinfecting  objects,  which  cannot  be  boiled  withoui  destruction,  such  as 
catgut  or  marine  sponges,  the  latter  being  Boaked  in  ">  per  cent,  carbolic 
lotion  for  two  to  three  weeks,  the  lotion  being  changed  a  few  times.  Allusi  m 
has  already  been  made  to  the  danger  of  using  carbolic  compresses,  even 
when  dilute,  to  small  parts,  such  as  Bngers,  since  owing  to  its  great  penetrat- 
ing powers  Bloughing  often  results.  Moreover,  if  used  to  wash  out  large 
cavities  or  on  wide  surfaces  it  may  be  absorbed  and  cause  general  poisoning, 
shown  by  a  greenish  colour  of  the  mine,  collapse,  and  syncope.  Hence  in 
BUch  cases  it   should   he  always  used  with  caution  and   not  left   in  a  cavity 

alter  irrigation. 

Mercurial  Salts.  The  perchloride  and  the  biniodide  are  both  used. 
the  latter  being  the  better  of  the  t  wo,  since  it  is  less  irritating,  more  penet  rat- 
ing, and  stronger  in  its  antiseptic  powers.  These  salts  are  used  in  strengths 
of  1  in  loon  to  |  in  10,000,  or  even  more  dilute,  lor  washing  the  hands  of 
blood  while  operating,  irrigating  cavities,  &c.,  or  sterilizing  such  things  as 
catgut.  These  solutions  must  never  be  left  in  cavities  lest  absorption  and 
mercurial  poisoning  ensue.  The  oxycyanide,  I  in  2000  to  I  in  4000,  is  a 
useful  non-irritating  antiseptic  for  urinary  work  (bladder  washes.  &c). 

[odine,  I  to  d  per  cent,  in  rectified  spirit,  is  an  excellent  and  safe 
antiseptic  for  preparing  the  skin  before  operative  procedures,  or  for  render- 
ing sterile  accidental  wounds,  being  strongly  antiseptic  and  but  slightly 
irritating. 

Substances  which  Set  Free  Nascent  Oxygen,  (a)  Peroxide  of 
hydrogen  (10  to  20  volumes  in  strength)  is  very  useful  for  irrigating  foul 
cavities,  such  as  appendix  abscesses,  and  acts  not  only  by  the  oxygen  set 
tree,  but  also  from  the  mechanical  frothing  as  this  occurs,  which  scours 
out  the  cavity  from  its  depths. 

(b)  Sanitas.  in  a  milder  way,  is  a  useful  deodorant  antiseptic. 

(c)  Permanganate  of  potassium  (I  in  2000)  may  be  used  to  irrigate  foul 
cavities  ;  its  astringent  action  makes  it  also  of  service  in  treating  gonorrhoea] 
urethritis. 

Formalin  is  a  powerful  antiseptic,  but  is  too  irritating  and  desiccating 
in  its  action  for  use  on  living  tissues.  Its  main  use  is  lor  sterilizing  instru- 
ments which  cannot  be  boiled,  such  as  cystoscopes,  bougies,  eve  ;  lor  such 
purposes  the  vapour,  confined  in  a  chamber,  is  employed. 

Lysolj  a  compound  of  soap  with  crude  phenol,  is  useful  from  its  soapy 
nature  to  clean  instruments,  or  in  dilute  solution  (15  minims  to  a  pint  of 
water)  to  irrigate  cavities,  or  for  baths  to  soak  parts  where  superficial 
incisions  have  been  made  for  cellulitis,  &c.  .Mixed  with  spirit  it  is  a  service- 
able means  of  sterilizing  knives  and  other  instruments  which  might  be  blunted 
by  boiling. 

Izal,  creolin,  kerol,  &c,  are  useful  deodorant  antiseptics  akin  to  creosote. 

Iodoform  is  a  very  weak'  antiseptic,  chiefly  characterized  by  its  odour, 
and    it    is    supposed    to    set     free    iodine    in    the    presence    of    pus,    and     be 


PREPARATIONS  FOR  OPERATIONS  147 

specially  inimical  to  the  tubercle  bacillus,  but  it  can  readily  be  dispensed 
with. 

Boric  acid  is  also  a  weak  antiseptic,  but  astringent,  and  so  useful  for 
irrigating  the  eye  or  bladder,  and  for  fomentations  which  are  made  by 
saturating  lint  in  a  solution  of  the  acid  and  allowing  it  to  dry. 

PREPARATIONS   FOR   AN   OPERATION 

(Note  whenever  an  operation  is  described  in  this  book  it  is.  of  course, 
understood  that  it  is  to  be  carried  out  with  all  aseptic  and  antiseptic  precau- 
tions as  here  detailed.) 

These  preparations  concern  the  operating  room,  the  patient,  the  surgeon, 
his  assistants,  and  the  materials  used  in  operating  (instruments,  dressings, 
ligatures,  swabs),  &c. 

The  Opekating  Room.  The  main  considerations  here  are  the  prevention 
of  dust-infections  and  avoiding  shock  by  the  maintenance  of  a  tolerably 
high  temperature.  Hence  if  operating  in  a  private  house  the  room  should 
be  cleaned  at  least  twenty-four  hours  before  operating  to  allow  the  dust 
to  settle,  otherwise  rooms  are  best  left  unscoured  :  a  tire  lit  some  hours 
before  will  provide  warmth  and  ventilation.  In  hospitals  operating  rooms 
are  built  with  special  precautions  :  the  walls  smooth  and  washable  (tiles 
or  enamel  paint)  ;  the  floor  impervious,  of  smooth  concrete,  sloping  to  a 
drain  which  is  efficiently  trapped.  There  should  be  as  few  shelves  and 
projections  as  possible  which  may  retain  dust,  and  for  this  reason  the 
corners  of  the  walls,  floor,  and  ceiling  are  rounded  off.  Every  day 
or  immediately  after  operations  on  infectious  cases  the  room  should  be 
filled  with  steam,  which  condenses  on  the  walls,  carrying  with  it  the  dust 
and  any  micro-organisms  therein  contained.  The  walls,  floor,  and  ceiling 
should  be  cleaned  with  antiseptic  solutions  at  regular  intervals.  Arrange- 
ments should  be  made  to  maintain  a  constant  temperature  of  70°  to  75° 
by  steam-heating.  A  north  light  is  advantageous,  but  as  at  least  half  the 
operations  in  a  large  hospital  are  of  necessity  performed  by  artificial  light, 
this  is  of  not  such  great  importance. 

The  Patient.  The  preparation  of  a  patient  for  a  general  anaesthetic 
has  been  described  in  the  previous  section  on  Anaesthesia  ;  there  remains 
to  be  considered  the  field  of  operation.  The  patient's  skin  is  rendered 
sterile  as  follows  :  In  urgent  cases  the  part  is  dry  shaved  it  accessary,  and 
two  coats  of  2  per  cent,  iodine  solution  in  rectified  spirit  applied,  allowing 
each  to  dry.  Where  there  is  time  for  preparation  the  skin  is  washed  ami 
shaved  over  night  ;  next  morning  the  iodine  solution  is  applied  an  hour 
before  operation,  and  the  part  covered  with  a  sterile  towel,  and  another 
coat  applied  immediately  before  the  operation.  Care  should  he  taken  to 
sterilize  a  much  wider  area  than  that  likely  to  be  invoked  in  the  operation 
lest  the  slipping  of  the  surrounding  towels  introduce  an  element  of  sepsis 
into  the  operation.  The  results  of  the  iodine  method  are  so  good  that  the 
older  plan  of  preparing  a  day  before  with  shaving,  washing  with'soap  and 
water,  cleansing  with  ether,  followed  by  biniodide  solution,  which  in  turn 


148  A  TEXTBOOK  OF  8URGERTZ 

was  replaced  by  a  compress  of  weak  carbolic  solution,  is  hardly  worth 
considering,  since  the  plan  was  most  tedious  to  the  patienl  and  liable,  if 
carried  out  very  carefully,  to  cause  considerable  irritation  of  the  skin.  There 
are  many  other  plans  of  disinfecting  the  skin,  but  the  method  described 
i-  as  good  as  any.  Mucous  surface  may  be  cleaned  by  irrigation  with 
biniodide  of  mercury  in  dilute,  watery  solution,  where  tins  is  possible, 
as  the  urethra.,  vagina,  conjunctiva  :  dilute  lysol  or  peroxide  of  hydrogen 
may  also  be  employed.  Complete  sterilization  of  mucous  surfaces  is  seldom 
possible.  Infective  foci,  e.g.  carious  teeth,  should  be  removed  from  the 
field  of  operation  several  days  before  the  operation  is  performed. 

The  Surgeon  and   his  Assistants,     (mod   results  may  be  obtained 
in  emergencies  by  turning  up  the  shirt  sleeves,  washing  the  hands  in  soap 
and  water,  and  soaking  them  for  a  few  minutes  in  solution  of  biniodide  of 
mercury  (1  in  500  spirit).     But  in  conducting  large  operations  and  where 
a  series  of  cases  of  all  kinds  follow  each  other,  some  being  of  a  highly  infective 
nature,  as  in  hospital  practice,  the  utmost  care  is  needed,  and  the  personal 
equipment  of  those  engaged  in  the  operation  can  hardly  be  thought  out 
with  too  much  minuteness.     The  surgeon  and  his  assistants  should  wear 
sterile  overalls  reaching  to  the  feet,  fastening  at  the  back,  and  with  sleeves 
reaching  to  the  wrist,  which  are  tucked  into  sterile  rubber  gloves.     Under 
tic  overall  a  mackintosh  apron  may  be  worn,  the  surgeon  stripping  according 
to  his  need.     The  best  clothing  of  all  is  a  suit  of  sterile  ducks  and  canvas 
shoes  or  rubber  boots.     The  face  and  head  are  best  covered,  especially  if 
the  surgeon  be  talkative,  perspire    freely,  or  have  a  scurfy  head,    only 
the  eves  appearing  from  the  sterile,  mask  or  head-piece.     The  hands  should 
he  well  kept  and  trimmed  as  to  the  nails  and  surrounding  skin;    if  used 
for  examining  dirty  matters,  as  in  pathological  work,  making  rectal  examina- 
tions. &c,  rubber  gloves  or  finger-cots  should  be  habitually  worn.     If  such 
precautions  be  adopted  the  hands  will  never  be  very  dirty.     Before  an 
operation  the  hands  should  be  washed  well  in  soap  and   water  to  which 
lvsol  or  soap  solution  is  added,  as  far  as  the,  elbows  for  several  minutes. 
and  then  soaked  in  the  solution  of  biniodide  of  mercury  in  spirit  (1  in  500) 
for  five  minutes.     Hands  treated  in  this   manner  are  sterile  enough  for 
practical  purposes,  but  as  an  extra  precaution  sterile,  rubber  gloves  should 
he  worn,  which  should  be  very  thin  and  roughened  on  their  outer  surface 
so  as  to  afford  a  good  grasp  of  slippery  tissues.     If  lubricated  internally 
with  sterile  glycerine  these  gloves  aTe  more  readily  put  on  and  save  (he 
hands  from   much  ill-usage,  being  of  service  not  only  to  the  patient  but 
the  surgeon  as  well.     When  used  habitually  gloves  interfere  little  with  the 
ease  of  manipulation;    care  should  be  taken  to  see  that  gloves  are   not 
punctured  before  putting  them  on,  and   if  punctured  at  operation  from 
needles  or  spicules  of  bone  they  should  be  immediately  changed.     Dining 
operation  the  blood  and  fat,  which  renders  them  very  slippery,  is  washed 
from  the  gloves  or  hands  by  frequently  dipping  them  in  sterile  water  or  a 
dilute  solution  of  antiseptic,  such  as  biniodide  of  mercury  in  water  (1  in  5000). 


MATERIALS  USED  IN  OPERATIONS  149 

THE   MATERIALS   USED   IN    OPERATIONS 

Swabs.  Squares  of  gauze  with  in- turned  edges  to  avoid  fraying  have 
largely  replaced  sponges,  are  sterilized  by  superheated  steam  like  other 
dressings,  and  can  be  kept  practically  indefinitely  in  air-tight  boxes  :  in 
emergencies  boiled  linen,  cotton-wool,  Sec.,  will  take  the  place  of  such  swabs. 
Marine  sponges,  though  under  the  ban  of  the  more  rigid  apostles  of  asepsis 
and  of  economic  experts  (from  the  difficulty  in  rendering  them  absolutely 
sterile  and  their  expense),  still  have  their  uses.  Where  there  is  really  severe 
bleeding,  as  when  a  large  artery  or  vein  is  torn,  or  where  a  large  effusion 
has  to  be  removed,  the  greater  power  of  absorption  of  marine  sponges  will 
save  time  and  possibly  life  as  well.  They  can  be  rendered  practically  sterile 
by  soaking  constantly  for  three  weeks  in  5  per  cent,  carbolic  lotion,  changed 
repeatedly.  Care  is  needed  to  wash  out  the  carbolic  thoroughly  before 
introducing  them  into  the  abdomen,  and  if  soiled  with  infective  material 
it  is  better  not  to  use  them  any  more.  Sponges  and  swabs  should  always 
be  in  packets  of  a  definite  number  to  allow  of  coimting  before  the  wound 
is  closed  so  that  no  risk  is  run  of  inadvertently  leaving  some  behind  in  the 
operation  woimd,  to  be  later  a  source  of  abscesses  and  much  litigation. 

Ligatures  and  Sutures.  Many  substances  are  employed  ;  the  perfect 
material  has  yet  to  be  found,  viz.  one  which  will  last  for  six  to  eight  weeks 
and  then  be  absorbed,  and  which  can  be  rendered  perfectly  sterile. 

Silk,  linen,  cotton,  and  celluloid  thread  are  all  used  for  deep  sutures  and 
ligatures.  They  are  readily  sterilized  by  boiling,  and  are  used  in  different 
thicknesses  according  to  the  tissues  sutured.  Boiling  for  thirty  minutes, 
followed  by  preservation  in  alcohol,  is  a  usual  plan. 

These  ligatures  are  not  absorbed,  but  remain  in  the  tissues  indefinitely  : 
for  this  reason  they  should  not  be  used  in  inflammatory  foci,  such  as  abscesses, 
or  a  sinus  is  likely  to  persist  till  the  ligature  works  out.  As  ligatures  these 
materials  have  the  advantage  of  securing  a  firmer  hold  than  catgut,  and 
not  slipping  off  when  applied  under  difficult  conditions,  as  when  applying 
a  lateral  ligature  to  a  vein. 

(  atgut  has  the  advantage  of  beiug  absorbable  if  suitably  prepared,  but 
owing  to  its  origin  and  the  mode  of  preparing  the  crude  substance,  care 
is  needed  to  produce  a  reliably  sterile  article.  Many  methods  have  been 
employed  to  sterilize  catgut.  The  iodine  method  is  simple  :  in  this  plan 
the  crude  gut  is  soaked  in  a  1  per  cent,  solution  each  of  iodine  and  potassium 
iodide  in  watery  solution  for  fourteen  days,  after  which  it  is  kept  dry  or 
in  spirit.  If  kept  too  long  in  the  iodine  the  gut  will  become  rotten  and 
break  readily. 

Soaking  the  gut  inbiniodide  of  mercury  (1  in  500  spirit),  boiling  in  xylol, 
or  soaking  in  picric  acid,  are  also  good  methods.  Prepared  by  the  above 
methods  the  gut  is  absorbable  and  disappears  from  the  tissues  in  one  to 
three  weeks  :  it  can  be  rendered  more  resistant  by  treatment  with  chromic 
acid  or  formalin  before  sterilizing.  If  strongly  ehromicized  catgut  becomes 
very  slightly  absorbable  and  may  be  found  in  the  tissues  after  months  or 


150  A  TEXTBOOK  OF  SURGERY 

years;     moderately   chromicized   catgul    is   useful    Eor  deep   Butures,    bul 
sometimes  fails  in  perfecl  sterility. 

Silkwonn-gut  is  readily  Bterilized  by  boiling,  as  are  metal  skin-clips 
(Michel's)  and  wires,  screws,  plates,  &c.,  for  bone  operations. 

Kangaroo  tendon,  which  is  employed  by  some  for  deep  sutures,  is  strong 
and  slowly  absorbed  :  this  material  is  sterilized  by  long  soaking  in  5  per 
rent,  carbolic  acid  solution. 

Dressings.  Simple  plain  gauze,  sterilized  by  superheated  steam,  isthe 
most  generally  useful  dressing.  Where  the  wound  is  certain  to  discharge,  as 
after  opening  an  abscess,  gauze  impregnated  with  the  double  cyanide  of 
mercury  and  zinc  (cyanide  gauze)  is  preferable,  as  the  contained  antiseptics 
prevent,  to  some  clegree,  further  decomposition  of  the  discharge. 

Iodoform  gauze  may  be  used  to  pack  foul  cavities,  hut  lias  little  advantage 
over  plain  gauze.  Boric  lint,  useful  for  fomentations,  has  already  been 
described  :  the  boiling  water  poured  upon  it  in  making  a  fomentation 
renders  it  sufficiently  sterile. 

The  patient,  surgeon,  and  materials  and  instruments  are  thus  rendered 
sterile,  and  only  practice  is  required  to  carry  out  the  technique  efficiently. 
The  cardinal  rule  of  asepsis  is  to  remember  that  any  instrument,  ligature, 
finger,  &c.,  which  has  touched  any  unsterilized  object,  is  to  be  regarded 
as  unclean,  and  discarded  or  resterilized.  Continued  practical  experience 
in  operating  theatres  is  needed  to  give  the  natural  reflex  inhibition  to 
scratch  the  uose,  handle  unsterilized  furniture,  such  as  a  stool,  with  the 
previously  sterilized  hands,  or  other  similar  actions  betraying  a  want  of 
a  full  appreciation  of  the  rules  of  surgical  cleanliness. 

Having  made  all  the  above  arrangements  the  patient  is  anaesthetized 
and  placed  in  position  for  operation.  It  is  important  to  arrange  the  patient 
bo  that  he  is  in  the  position  of  greatest  ease  for  the  surgeon,  without 
impeding  the  administration  ol  the  anaesthetic  or  his  own  well-being. 
Special  positions,  such  as  the  lithotomy  position  for  perineal  opera- 
tions, or  that  of  Trendelenberg  for  pelvic  operations.  &c,  are  described 
in  later  sections.  When  the  patient  is  suitably  arranged  the  sterile  covering 
is  removed,  packing  of  sterile  towels  placed  round  and  under  the  seat  of 
operation,  the  skin  painted  with  the  final  coat  of  antiseptic  solui  ion.  Sterile 
towels  and  sheets  are  tixed  around  the  operation  area,  and  the  field  is  ready 
for  operation.  Towels,  &c.,  surrounding  the  operative  field  should  extend 
a  good  distance  around,  so  thai  the  whole  patient  is  enveloped  and  should 
be  fixed  tighl  around  the  site  of  operation  with  clips  or  sutures  to  prevenl 
their  slipping  and  possibly  nibbing  material  from  some  unsterilized  part 
of  the  body  over  the  site  of  operation. 

Si  bgical  Incisions.  The  belly  of  the  knife  is  the  pari  to  cut  with, 
and  not  the  point,  which  is  the  mistake  of  most  beginners.  The  poinl  is 
useful  for  dissecting  later  in  an  operation.  The  incision  should  he  planned 
beforehand  <>l  adequate  size,  and  the  less  the  skill  of  the  surgeon  the  larger 
the  incision  oughl  to  he.  There  should  he.  however,  no  hesitation  in  enlarg- 
ing an  incision  if  it  is  obviously  too  small  ;   good  work  is  often  spoiled  by 


INCISIONS  AXD  THEIR   CLOSURE 


151 


Fig 


Interrupted  sutures. 


is 


attempting  to  operate  through  too  small  an  opening.  At  the  same  time 
there  is  no  need  to  perform  unnecessary  dismemberment.  A  little  thought 
will  generally  decide  early  in  an  operation  if  the  incision  needs  enlarging. 
Thus  if  a  3-inch  incision  is  usually  needed  for  a  given  operation,  should  the 
patient  be  enormously  fat  an  incision  of  5  or  0  inches  may  be  none  too 
large.  The  advantages  of  incisions  of  different  sorts  and  directions  are 
discussed   in  the  surgery  of  \ 

special  parts,  such  as  the 
neck,  abdomen,  &c.  The  in- 
cision should  be  of  equal 
extent  throughout  its  depth, 
and  not  tail  off,  becoming 
less     in     length    as    deeper 

structures  are  reached,  except  in  special  instances.  Hemorrhage 
arrested  as  required  by  the  application  of  clip  forceps  (Spencer  Wells), 
and  if  this  can  be  done  before  the  vessel  is  divided  so  much  the  better. 
General  oozing  is  controlled  by  pressure,  hot  lotion,  or  the  application  of 
adrenalin  ;  the  various  methods  of  dealing  with  ha?morrhage  and  bleeding- 
points  are  further  discussed  in  the  section  on  Blood- Vessels. 

Methods  of  Closing  Open  Wounds.  There  are  many  available 
methods  serviceable  alike  for  accidental  or  operative  wounds.  In  most 
instances  wounds,  if  of  any  considerable  depth,  should  be  closed  in  layers 
to  prevent  accumulation  of  serum  in  the  interior,  which  "  pockets " 
and  readily  affords  place  for  organisms,  liable  to  lead  to  infection  and 
suppuration  ;    further,  by  accurate  replacement  of  parts  which  have  been 

cut,  the  part  is  made 
much  stronger,  and  such 
troubles  as  hernia,  mus- 
cular weakness,  &c.,  can 
largely  be  obviated. 
Both  continuous  and 
interrupted  suturing  is 
suitable  according  to 
the  part  to  be  sutured. 

Where  there  is  cer- 
tain to  be  considerable 
tension,  as  in  the  ab- 
dominal wall,  at  least 
one  layer  of  deep  sutures 
should  be  interrupted.  Chromic  catgut  is  useful  for  deep  sutures,  but  silk 
or  plain  sterile  catgut  may  lie  used;  the  former,  however,  has  an  unpleasant 
way  of  separating  and  working  out  on  the  surface  even  after  years  of  quietude, 
especially  if  near  the  skin,  while  the  latter  is  likely  to  be  absorbed  too  rapidly 
unless  of  very  thick  and  clumsy  calibre.  Continuous  sutures  for  deep  struc- 
tures are  passed  in  the  ordinary  overhand  manner  ;  there  is  no  particular 
object  in  using  the  blanket-stitch.     Interrupted   sutures  may  be  inserted 


r_'.     '/.   Mattress  suture  to   relieve  tension.     /', 
tinuous  suture,  and  method  of  finishing  off. 


1 52 


\  TEXTBOOK  OF  Bl  RGERY 


simply,  or  in  the  mattress  fashion,  and  if  passed  in  the  latter  manner  may 
be  made  eithei  to  invert  or  evert  the  tissues  sutured  according  as  seems 

I  likely  to  secure  best  apposition. 

4 


<f*>» 


I 


,ii>aitilTliriii  it, ft 


FlQ.   \:\. 


& — £ 

Mattress  suture  causing  eversion  uf 
the  edges  of  the  wound. 


WWm- 


Fig.  14. 


Mattress  suture  causing  inversion  of 
the  edges  of  the  wound. 


Mattress  sutures  are  especially 
indicated  where  single  sutures 
begin  to  tear  through.  (Figs.  [:>. 
ll.  i:».  46.) 

Suture  of  the  Skin.  Inter- 
rupted sutures  of  silkworm-gut 
give  in  general  the  best  apposi- 
tion :  continuous  catgut  used  as 
a  simple  or  blanket-stitch  also 
gives  very  fair  apposition,  but  less 
good.  This  is  a  more  rapid  method 
and  useful  for  suturing  very  long 
incisions  where  speed  is  needful. 
Michel's  metal  skin-clips  are 
effective  and  rapid  in  the  hands 
of  those  who  use  them  habitually, 
but  can  only  be  used  where  there 
is  little  or  no  tension.  If  re- 
moved early  the  scar  is  very 
.slight,  but  if  fastened  too  tight 
they  cause  as  much  scarring  as  interrupted  sutures.     (Fig.  48.) 

The  subcuticular  suture  of  Halstead  is  of  service  where  the  most  insignifi- 
cant scar  is  essential,  as  on  the  face,  neck,  or  breast  of  women  ;  the  suture 
is  passed  from  side  to  side  of  the  wound  just  below  the  epidermis  without 
coming  out  on  the  surface  except  at  the  two  ends.  Silk  must  be  used  for 
subcuticular  sutures  ;  if  silk- 
worm-gut is  employed  the  suture 
cannot  be  withdrawn  and  has  to 
be  dug  piecemeal,  spoiling  the 
scar.  Normally,  the  subcuti- 
cular stitch  is  removed  on  the 
tilth  day  by  pulling  lightly  on 
ad  and  cutting  it  off  through 
a  part  which  has  been  buried, 
and  then  pulling  the  other  end, 
when  the  suture,  if  of  silk,  comes 
readily  away  on  quite  gentle 
traction. 

Results  almost  as  good  as  with  the  last  method  are  obtained  by  suturing 

the  subcutaneous  tissues  (in  the  neck,  the  platysma)  with  tine  interrupted 

catgut,   and   the  .skin    with    very  fine  silkworm-gut,  or    fastening   it    with 

Michel's  clips,  eithei-  of  which  are  removed  on  the  fourth  day.  thus  leaving 

car.     Where  the  skin  will  ll(,t  come  together  readily  after  an  operation. 


Fig.  45.     Continuous  inverting  mattress  suture. 


^>; 


T  \  T  1  L 

~A  .»  '  ■>:-*>< '"»*•  i-W.v- ?**&! TT  vr*.'-.-..-? 


Fig.   16.     Continuous  everting  mattress  suture 
(Glover  or  Council's  suture). 


SUTURING  WOUNDS 


153 


Fig.  47.     Tying  sutures.     A,  Reef  knot.     B,  Sur- 
geon's knot;  the  first  hitch  is  double,  and  does  not 
slip 


as  after  the  orthodox  excision  of  the  breast,  it  will  be  necessary  to  under-cut 
the  surrounding  skin  widely  for  several  inches,  and  pull  the  edges  together 
with  stout  silk  sutures  inserted  some  2  inches  from  the  edge  to  relieve  the 
strain  on  the  small  sutures  which  bring  the  edges  into  apposition.  Some 
wind  these  tension  sutures  round  lead  buttons,  but  this  does  not  seem  a  in- 
great  advantage.  When  insert- 
ing interrupted  skin  sutures 
it  is  advisable  to  produce 
slight  eversion  of  the  extreme 
edge  (just  as  is  done  with 
Michel  clips),  so  that  the 
scar  forms  a  weal  till  the 
sutures  are  removed  :  this 
obviates  the  risk  of  non- 
union from  inversion  of  the 
skin  and  gives  a  firm  scar. 
Before  closing  the  wound  it  should  be  quite  dry.  and  all  the  bleeding- 
points  stopped.  Where  a  large  area  has  been  laid  bare  and  considerable 
oozing  is  bound  to  take  place,  as  after  removal  of  the  breast  or  amputation 
of  a  limb,  a  stab  puncture  should  be  made  at  the  most  dependent  part 
of  the  wound,  and  a  drainage-tube  inserted  for  twenty-four  to  forty- 
eight  hours  to  allow  of  the  escape  of  the  serum 
which  may  otherwise  lead  to  suppuration. 

The  dressing  applied  varies  with  the  kind  of 
operation.  Thus  if  a  large  wound  has  been  made, 
and  there  will  certainly  be  much  exudation  of 
serum,  firm,  general  pressure  over  the  wounded 
area  will  be  beneficial.  In  such  cases,  therefore,  it 
will  be  well  to  place  a  considerable  amount  of 
sterile  gauze,  and  over  this  sterile  wool  as  a  cover- 
ing, and  bandage  the  whole  firmly  with  an  elastic 
bandage,  of  which  those  made  of  "  domette  "  are 
a  good  type.  Where  little  exudation  is  likely  a 
dressing  of  collodion  and  gauze  may  be  used;  a 
thin  strip  of  gauze,  fastened  on  the  incision  with 
acetone  collodion,  makes  an  excellent  dressing  for 
minor  wounds,  and  is  especially  useful  where  there 
is  a  chance  of  the  dressings  being  soiled  with  urine  or  faeces,  as  in  the 
groins  of  children  and  infants  after  hernia  operations. 

After-treatment.  As  far  as  this  concerns  recovery  from  anaesthesia  this  has 
been  discussed  under  Anaesthetics  ;  the  minor  measures,  cleaning  the  month 
and  giving  a  dose  of  phenacetin  and  caffein,  will  often  render  a  patient  on 
recovery  more  comfortable.  Pain .  when  the  patient  has  recovered  conscious- 
ness, is  counteracted  by  hypo<  lei  m  ics  of  morphia,  and  sleep  secured  for  the  first 
night  after  severe  operations  bymorphia  or  hypnotics,  trional,  chloralamide, 
&c.     Shock  is  prevented  by  the  use  of  warm  bottles  and  saline  infusions. 


Is.     Michel's  clips — 
section     and      when 
applied. 


154  A  TEXTBOOK  OF  SURGERY 

Dressing  Cases  aeteb  Operation.  Dressing  a  wound  is  performed 
under  equally  strict  rules  of  asepsis  as  those  employed  in  operating;  the 
surroundings  are  covered  with  Bterile  towels,  and  the  dressings  removed 

with  sterile  instruments  or  hands.  Where  a  tube  lias  been  inserted  tin' 
dressing  is  changed,  usually  in  twenty-four  hours,  and  the  tube  removed  : 

if  there  is  much  discharge  of  serum  the  tube  may  he  left  in  situ  for  another 
day.  though  this  increases  the  risk  of  some  infection  spreading  up  the  tuhe- 
channel  from  the  skin.  Where  there  is  no  drain  the  dressing  may  be  left 
in  position  for  seven  to  ten  days  unless  there  seems  reason  to  investigate 
the  wound.  With  this  in  view  the  pulse  and  temperature  are  watched. 
and  if  there  is  fever  after  the  first  twenty-four  hours,  with  pain  in  the  wound. 
it  will  he  wise  to  dress  the  case  and  examine  the  wound  unless  there  is  some 
obvious  cause  for  fever,  such  as  an  intercurrent  attack  of  tonsillitis.  If 
the  wound  appears  inflamed  some  stitches  should  he  removed,  and  drainage 
established.  The  dressing  of  septic  cases,  e.g.  colotomies,  abscesses,  should 
lie  done  as  often  as  is  necessary,  four-hourly,  or  even  oftener,  according 
to  the  amount  of  discharge.  Drainage-tubes  should  be  removed,  if  possible 
within  four  days,  to  prevent  the  formation  of  sinuses. 

Where  after  an  operation  the  dressing  is  rapidly  soaked  through  with 
blood,  if  tin1  patient "s  condition  is  good  attempt  may  be  made  to  stop  the 
bleeding  by  firm  bandaging  over  an  extra  supply  of  gauze  and  wool.  Should 
the  bleeding  pass  through  this  the  dressing  should  be  removed  and  the 
wound  inspected,  and  if  blood  be  then  found  oozing  from  drainage-tube 
and  stitch-holes  the  wound  should  be  opened  up  and  bleeding-points  sought 
for  ;  if  only  a  general  oozing  is  found,  the  wound  should  be  packed  with 
gauze  soaked  in  adrenalin,  and  brought  partially  together  with  a  few  sutures 
and  firmly  bandaged  over  plenty  of  dressing. 

In  addition  to  observing  the  temperature,  the  respiratory  system  should 
he  under  observation,  since  lung  troubles  are  not  infrequent  after  operations, 
especially  those  under  general  anaesthesia  ;  bronchitis  and  pneumonia  will 
need  treatment  as  described  in  works  on  medicine. 

The  passage  of  mine  should  be  noted.  Thus  anuria  may  follow  renal 
or  nt  Imt  operations  on  patients  wit  h  damaged  kidneys,  in  which  case  iliuret  ics. 
Cardiac  stimulants,  an  infusion  of  saline  intravenously,  will  he  indicated. 
Much  more  common  is  retention  of  urine,  which  so  often  follows  operations 
about  the  rectum,  groin,  &c,  and  the  attendant  must  always  be  prepared 
for  its  occurrence  after  such  minor  operations  as  that  for  varicocoele,  and 
not  Leave  patients  for  many  hours  alter  an  operation  of  this  sort  without, 
ascertaining  that  they  are  able  to  micturate  normally  :  passing  a  catheter 
if  unable  to  promote  the  flow  by  means  of  fomentations  to  the  perineum 
or  hypogastrium. 

Feeding  apteb  Operations.  This  also  very  largely  depends  on  the 
effect  of  the  anaesthetic  and  the»amoun1  of  vomiting.  In  most  instances 
the  patient  is  kept  on  hot  water  and  mouth-washes  for  about  six  hours  ; 
then  weak  tea  or  milk  and  soda  for  another  six  hours,  after  which  thin 
bread-and-butter,  a  lightly  hoiled    egg-  &c,  can  often    he  taken.     Normal 


AFTER-TREATMENT  L55 

diet  can  be  commenced  about  the  third  day  when  the  bowels  have  been 
opened. 

Children,  and  particularly  infants,  require  feeding  early.  Thus  after 
an  operation  for  intussusception  in  an  infant,  feeding  should  be  commenced 
as  soon  as  the  little  patient  is  sufficiently  round  to  swallow  and  the  first  or 
anaesthetic  vomiting  has  passed  off.  In  old  persons  also  feeding  should  be 
commenced  early,  and  alcoholic  stimulants  freely  given  if  their  powers  are 
failing.  The  bowels  are  usually  opened  with  castor-oil  on  the  third  day, 
but  earlier  if  there  is  trouble  with  flatulence,  for  which  last  also  oil  of  cajuput, 
2  minims  every  quarter  of  an  hour,  may  be  given  for  six  doses,  or  a  turpentine 
enema. 

Delirium  and  shock  have  already  been  discussed  (pp.  112,  114). 

Vomiting  after  operations  is  usually  due  to  the  anaesthetic  or  some  abdo- 
minal condition  not  completely  relieved  by  the  operation.  When  due  to 
anaesthesia  small  drinks  of  very  hot  water,  washing  out  the  stomach  with 
dilute  soda  solution,  minim  doses  of  tinct.  capsici  or  tinct.  iodi  for 
six  doses,  are  helpful  ;  watch  should  be  kept  for  acidosis  (in  breath  and 
urine),  where  vomiting  is  continuous  after  administration  of  chloroform, 
or  acute  dilatation  of  the  stomach,  both  of  which  are  improved  by  washing 
out  the  stomach  with  2  per  cent,  soda  lotion,  and  the  former  by  doses  of 
sodium  bicarbonate.  Where  the  vomiting  is  due  to  some  unrelieved  abdo- 
minal condition,  such  as  peritonitis,  the  advisability  of  further  operation 
must  be  considered,  and  if  that  is  out  of  the  question  washing  out  the 
stomach  and  getting  the  bowels  open  with  calomel,  pituitary  extract,  and 
turpentine  enemata  is  the  only  resource. 


CHAPTEB  X 

PARASITIC   AND   INFECTIVE    DISEASES 

Varieties  of  Infection  :  Specific  Infection  and  its  Diagnosis.  Agglutinating 
Tests,  Deviation  of  the  Complement  (serum  reaction):  General  Infections: 
Septicaemia  :  Pyaemia  :  Special  Infections  :  Pyogenic  Organisms  :  Staphy- 
lococci. Carbuncle  :  Streptococci,  Erysipelas,  Cellulitis  :  Cellulitis  of  special 
regions  :  Pneumococci :  Gonococci :  Soft  Sore  :  Glanders  :  Anthrax  :  Organisms 
found  in  Spreading  Gangrene  :  Vincent's  Organisms  :  Diphtheria  :  Tetanus  : 
Hydrophobia  :  Streptothrices  or  Mycobacteria  :  Tuberculosis  :  Modes  of 
Infection  and  Predisposing  causes  :  Anatomy  and  results  of  tuberculous  in- 
fect ion  :  Treat  ment  :  Actinomycosis  :  Leprosy  :  Protozoal  Diseases :  Dysentery : 
Malaria  :  Delhi  Boil  :  Syphilis  :  Acquired  and  congenital  forms  :  Stages:  Forms 
of  Chancres  :  Secondary  and  Tertiary  manifestations  :  Colles's  Law  :  Diagnosis 
of  Syphilis  :  Prognosis  and  Infectivity  :  Treatment  of  Syphilis  :  Yaws  :  Hydatid 

I  UseaSC 

Attention  has  already  been  drawn  to  the  importance  of  bacteria  in  causing 
disease.  Other  forms  of  living  beings  are  equally  responsible.  Thus  among 
the  more  highly  organized  fungi  is  found  the  cause  of  ringworm  (tinea)  ; 
a  lining  the  yeasts  the  blastomyces,  causing  an  unusual  form  of  dermatitis. 
While  of  protozoa  certain  amoebae  cause  dysentery,  of  spirillse  that  causing 
syphilis  is  second  to  none  in  importance,  and  the  plasmodia  to  which  malaria 
owes  its  being  cause  havoc  in  tropical  stations.  Among  animal  forms  the 
worms  preponderate  as  workers  of  evil,  and  of  these  cestodes  (hydatids), 
flukes  (bilharzia),  and  nematodes  (threadworms)  hold  first  place. 

We  have  already  explained  the  meaning  of  the  terms  infections,  bacil- 
lsemia,  immunity,  both  active  and  passive,  and  pointed  out  the  general 
plan  for  determining  the  nature  of  an  infection  by  carrying  out  Koch's 
postulates,  that  is  isolating  an  organism  in  a  pure  culture  and  showing  that 
it  will  produce  a  similar  disease  when  inoculated  into  another  subject.  In 
many  instances,  however,  it  is  difficult  or  impossible  to  grow  such  organisms, 
and  in  some  diseases,  although  obviously  infective,  no  organisms  have  yet 
been  detected.  We  have  then  to  rely  partly  on  the  specific  nature  of,  i.e.  the 
signs  and  symptoms  of.  the  disease,  partly  on  the  reaction  of  the  sera  of  the 
infected  patients  to  cultures  of  the  bacteria  responsible,  or  by  indirect  evi- 
dence as  that  given  by  the  "  deviation  of  the  complement  "  (Wassermann's 
reaction).  Some  writers  divide  infective  diseases  into  specific  and  non- 
specific, including  in  the  former  such  infections  as  enteric,  diphtheria, 
tetanus,  where  the  clinical  picture  is  in  each  instance  fairly  distinctive, 
relegating  to  the  non-specific  class  such  micro-organisms  as  produce  the 
common  effects  of  local  inflammation,  suppuration,  and  general  infection 
of  this  nature  described  as  septicaemia  or  pyaemia.     Nevertheless  specificity 

156 


SPECIFIC  INFECTIONS  157 

is  after  all  only  a  matter  of  degree  ;  the  lesions  of  the  so-called  non-specific 
organisms  (often  described  as  pyogenic)  are  in  truth  specific  for  each 
organism,  if  not  macroscopically  at  least  to  bacteriological  tests. 

Thus  the  streptococcus  tends  to  cause  a  diffuse  inflammation  or  cellulitis. 
or  erysipelas,  and  if  producing  pus  the  abscesses  are  ill-formed,  whereas 
the  staphylococcus  forms  well-defined  abscesses,  the  pneumococcus  causes 
the  formation  of  pus  containing  much  clotted  lymph,  and  attacks  for  choice 
serous  surfaces,  such  as  the  pleura  and  peritoneum.  The  gonococcus. 
which  is  essentially  a  pus-producing  organism,  attacks  most  readily  mucous 
surfaces,  such  as  the  urethra  and  conjunctiva,  but  in  addition  causes  inflam- 
mation and  suppuration  of  a  subacute  nature  in  serous  surfaces,  e.g.  the 
peritoneum.  The  typhoid  bacillus,  which  typically  produces  a  general 
infection  (enteric  fever),  can,  in  patients  whose  resistance  is  lowered  by 
such  general  infection,  act  as  a  pyogenic  organism,  causing  the  formation 
of  abscesses  in  bone  and  elsewhere. 

Diagnosis  of  Specific  Infections.  This  may  be  done  in  three  main 
ways. 

(1)  By  following  out  the  line  of  investigation  demanded  by  Koch's 
postulates,  which  may  be  impossible  from  our  inability  to  grow  the  organism 
in  pure  culture  ;  and  in  any  case  is  employed  rather  to  fix  an  infection  as 
a  definite  entity  than  for  clinical  investigation  of  individual  cases. 

(2)  By  investigating  the  serum  of  the  infected  patient,  which  may  be 
done  (a)  by  the  agglutinating  tests,  or  (6)  by  studying  the  "  deviation  of  the 
complement." 

(a)  The  serum  of  an  infected  patient,  when  added  to  an  emulsion  of 
the  bacteria  specific  of,  or  responsible  for  such  infection,  has  the  power  of 
causing  these  bacteria  to  collect  in  clumps.  This  "  clumping  "  can  be 
observed  under  the  microscope,  or  if  a  tube  of  the  bacterial  emulsion  and 
diluted  serum  be  left  for  some  hours  a  sediment  of  the  clumped  bacteria 
will  fall  to  the  bottom,  leaving  a  clear  upper  layer  in  the  tube  (sedimentation 
test). 

(6)  The  dcviaticn  of  comphn  en'  test  is  based  on  the  power  of  a  patient 
to  produce  antibodies  or  bacteriolytic  substances  in  his  serum  and  tissues, 
after  infection  with  a  pathogenic  organism.  Further,  it  has  been  found 
that  a  similar  power  is  exercised  towards  red  corpuscles  of  another  animal, 
and  by  making  several  injections,  e.g.  of  ox-corpuscles  into  a  rabbit,  the 
serum  of  the  latter  acquires  the  power  of  readily  disintegrating  the  corpuscles 
of  the  ox,  the  process  being  known  as  haemolysis.  It  has  been  found  that 
both  haemolysis  and  bacteriolysis  are  due  to  the  presence  of  two  different 
hoilies  in  the  serum  of  the  inoculated  animals,  and  unless  both  are  present 
together  there  is  no  action  of  "  lysis,"  i.e.  no  destruction  of  red  corpuscles  or 
bacteria.  The  two  substances  in  question  are  known  as  the  anti-body  or 
immune  l>  dy,  which  is  developed  by  tin1  inoculation  with  bacteria  or  cor- 
puscles, and  the  "complement"  or  •■  alexine  "  which  is  present  in  normal  serum 
and  is  the  actual  destroyer  of  corpuscles  or  bacteria,  but  cannot  act  unless 
the  immune  body  is  present.     Moreover,  the  complement  is  readily  destroyed 


158  \    rEXTBOOK  OF  SURGERY 

by  beating  serum  to  55  '  '..  so  that  it  is  possible  to  obtain  serum  containing 
either  tluv  immune  body  or  the  complement  alone.  The  effects  of  haemolysis 
being  readily  seen  (as  "  laking  "  of  the  blood)  form  a  convenient  reagent  to 
•rain  the  presence  or  absence  ol  complement  <>r  immune  body,  very 
much  as  litmus  solution  ami  other  dyes  arc  employed  as  indicators  to  test 
alteration  from  aridity  to  alkalinity  in  chemical  analysis.  Ox-corpuscles 
treated  with  the  serum  of  a  rabbit  (previously  inoculated  with  ox-corpuscles), 
but  heated  to  destroy  the  complement,  are  known  as  "  sensitized  corpuscles  " 
and  will  undergo  lysis  in  the  presence  oi  complement.  Such  sensitized 
corpuscles  form  a  test  for  free  complement,  and  if  not  undergoing  lysis 
show  that  the  complement  has  been  fixed  or  deviated.  In  the  original 
Wassermann  reaction  a  mixture  of  syphilitic  liver  (spirochetes)  was  mixed 
with  the  serum  of  the  patient  (anti-body),  heated  to  destroy  comple- 
ment, and  some  normal  guinea-pig's  serum  (complement).  The  anti-body 
fixed  the  guinea-pig's  complement  to  the  spirochetes,  and  if  sensitized 
corpuscles  were  added  no  haemolysis  occurred.  If  there  were  no  syphilitic 
anti-body  present  to  fix  the  complement  to  the  spirochetes,  the  complement 
of  the  guinea-pig's  serum  was  free  to  attack  the  sensitized  ox-corpuscles, 
and  haemolysis  took  place.  It  has  been  found  that  other  substances, 
e.g.  extract  of  guinea-pig's  or  ox-liver  when  added  to  syphilitic  serum,  will 
fix  the  complement,  so  that  the  reaction  as  at  present  performed  though 
serviceable  is  not  quite  satisfactorily  explained. 

GENERAL   INFECTIONS.     SEPTICEMIA,   PYEMIA,    BACILLEMIA 

It  has  already  been  pointed  out  that  some  infective  organisms  always 
remain  localized  at  whatever  point  of  the  body  they  attack,  and  produce 
their  effects  (the  disease)  by  dissemination  of  their  toxins  :  such  are  diph- 
theria and  tetanus.  Other  microbes  are  always  disseminated  throughout 
the  body,  producing  a  general  infection.  Moreover,  unless  they  are  thus 
disseminated  they  appear  unable  to  produce  any  local  effects.  Such 
organisms  are  those  of  enteric,  plague,  and  the  hitherto  undiscovered  causes 
of  the  exanthemata.  Another  group  of  infective  organisms  are  such  as 
are  usually  confined  to  one  part  producing  some  local  lesion,  such  as  abscess 
(staphylococcus),  sloughing  and  oedema  (anthrax),  but  may.  if  very  virulent 
or  if  the  resistance  of  the  patient  is  poor,  become  disseminated  throughout 
the  body,  setting  up  inflammations,  abscesses,  degenerations,  sloughings, 
&c.,  in  distant  pair-  of  the  body.  It  is  this  last  group  of  general  infections 
that  are  known  by  the  term  septicaemia  and  pyaemia.  We  must  recognize 
then  that  the  term  septicaemia  or  pyaemia  is  not  a  full  description  of  the 

-■•.  since  different  organisms  may  be  responsible  for  such  infections. 
The  terms  septicaemia  and  pyaemia  are  usually  confined  to  the  result  of 
general  infection  with  organisms  which  as  a  ml''  cause  abscess  formation 
or  <-'-llulitis.  such  a-  staphylococci,  streptococci,  gonococci,  pneiimococci ; 
but  general  infections  with  other  organisms  which  do  not  cause  suppuration 

unetimes  included,  e.g.  anthrax.  'I  bus  to  be  strictly  accurate  we  should 
speak   of   a    streptococcal,   pneumococcal,   or  glanders   septicaemia   or  an 


SEPTICEMIA    AND   PYAEMIA  159 

anthracsemia.  Tuberculosis  also  may  be  either  localized  or  generalized  ; 
in  the  latter  case  instead  of  calling  the  condition  one  of  tuberculous  septi- 
caemia, which  would  be  quite  correct,  the  term  miliary  tuberculosis  is 
commonly  used.  In  general  then  septicaemia  may  be  regarded  as  a  general, 
severe,  progressive,  blood-borne  infection,  or  bacillaemia,  with  some  organism 
which  commonly  produces  local  suppurative  or  cellulitic  lesions. 

Septicaemia  and  pyaemia  are  conditions  of  similar  nature,  but  differing 
in  degree.  The  formation  of  multiple  abscesses  in  the  latter  is  partly  from 
the  longer  time  in  which  the  infective  organisms  have  to  act,  partly  from 
the  manner  in  which  the  infection  spreads  by  thrombosis  of  veins  and 
embolism.  Pyaemia  is  essentially  a  more  chronic  condition  than  septicaemia. 
for  the  latter  is  either  fatal  before  there  is  time  to  develop  abscesses,  or 
the  patient  secures  immunity  against  the  infection  before  abscesses  are 
produced.  Intermediate  conditions  -occur  fairly  often,  which  may  be 
called  septieo-pvaemia.  Milder  types  of  general  infection  also  occur.  The 
production  of  cholecystitis,  leading  to  the  formation  of  gall-stones,  and  that  of 
duodenal  ulcer,  are  in  many  instances  almost  certainly  due  to  a  spread  of 
infection  from  disease  of  the  appendix  via  the  blood-stream  :  such  general 
spread  takes  place  with  little  evidence  in  the  way  of  clinical  signs.  The 
blood-borne  infections  with  tuberculosis  form  parallel  instances,  and  a 
tuberculous  kidney  secondary  to  a  caseating  bronchial  gland  may  aptly  be 
compared  to  duodenal  ulcer  following  on  a  chronic  appendicitis. 

Pathology.  Septicaemia.  In  this  condition  the  infecting  agent  enters 
the  blood-stream  in  the  form  of  small  particles,  e.g.  single  organisms  or 
small  colonies  (too  small  to  block  vessels  of  any  size),  but  in  great  numbers, 
and  these  rapidly  multiply  in  the  blood  and  tissues,  producing  changes  in 
the  walls  of  the  vessels  and  the  tissues.  In  cases  of  septicaemia  the  inner 
coats  of  the  arteries  are  often  red  from  hyperaemia,  the  valves  of  the  heart 
are  in  a  similar  condition  and  sometimes  show  vegetations  or  masses  of 
fibrin  attached  to  them,  the  result  of  inflammation  (endocarditis).  The 
viscera  are  soon  affected,  the  lungs  being  congested  and  oedematous  with 
exudation  into  the  alveoli  (pneumonia)  ;  the  liver  is  hyperaemic  and  shows 
the  cellular  alterations  known  as  cloudy  swelling  ;  the  spleen  is  large,  dark. 
soft,  very  hyperaemic,  and  sometimes  diffluent.  The  condition  admits  of 
recovery  up  to  a  certain  point  in  the  milder  grades  of  infection  :  usually 
such  infections  are  rapidly  fatal.  If  life  is  prolonged  abscesses  often  form 
in  the  inflamed  organs. 

Pycemia.  In  these  cases  the  infection  is  of  a  more  bulky  nature  in  the  form 
of  emboli,  large  enough  to  block  vessels  of  moderate  size ;  but  the  number  of 
these  foci  of  infection  travelling  in  the  blood-stream  is  far  smaller  than  is 
the  case  with  septicaemia.  Pyaemia  results  typically  from  infective  venous 
thrombosis.  The  thrombi  in  the  veins  break  down  under  the  action  of  the 
infecting  agents  (bacteria),  and  portions  becoming  detached  pass  into  the 
circulation  as  emboli.  These  free  travelling  portions  of  infective  clot,  or 
emboli,  journey  with  the  venous  blood  to  the  right  side  of  the  heart,  and 
thence  along  the  pulmonary  artery,  lodging  in  the  smaller  branches  of  the 


160  A  TEXTBOOK  OF  SURGERY 

Latter,  block  these  and  form  "infarcts"  or  hypersemic  wedges  of  lung- 
tissue  with  poor  blood-supply  :  then  the  infarcts,  being  foci  of  infection 
soon  break  down,  forming  secondary  abscesses.  Where  the  thrombosed 
vein  is  a  tributary  of  the  portal  system,  e.g.  arising  from  appendicitis  or 
thrombosed  hemorrhoids,  the  emboli  naturally  follow  the  portal  circulation 
and  land  in  the  liver,  where  they  give  rise  to  multiple  abscesses  of  the  liver, 
also  known  as  pylephlebitis  or  portal  pyaemia.  Rapid  painless  effusion  of 
l>us  into  large  joints  is  common  in  cases  of  pyaemia.  The  mode  of  such 
spread  is  uncertain  ;    if  drained  such  joints  may  recover  well. 

Clinical  Appearances.  In  a  typical  case  of  septicaemia  the  onset  is 
sudden  with  high  fever  ;  the  temperature  remains  elevated.  bu1  is  irregular, 
an  initial  rigor  is  common.  The  patient  feels  extremely  ill  with  headache, 
thirst,  general  weakness,  loss  of  appetite,  and  a  dirty  tongue,  which  soon 
becomes  dry,  brown,  and  cracked  where  the  condition  is  really  severe.  The 
fare  is  flushed  at  first,  later  may  be  of  a  yellowish  tinge.  Punctate  subcuta- 
neous haemorrhages  (petechia1)  are  fairly  common  on  the  chest,  abdomen,  or 
extremities  ;  the  pulse  is  rapid  and  soon  becomes  small  and  weak  ;  albumen 
in  the  urine  is  common  ;  there  may  lie  blood  and  casts  as  well.  After  two 
or  three  days  signs  of  pneumonia  will  often  be  noted  :  cough,  expectoration 
of  blood-stained  mucus,  or  pus.  and  areas  of  consolidation  discovered 
on  percussion,  showing  that  the  condition  of  pyaemia  is  being 
approached.  Delirium  is  common  in  the  early  stages  ;  stupor  or  coma 
vigil  heralds  in  the  end,  which  in  severe  cases  will  take  but  a  few  days. 
The  above  is  a  picture  of  the  more  severe  types.  Milder  degrees  of  this 
condition  also  occur,  which  are  clinically  indistinguishable  from  what  is 
often  described  as  saprcsmia  or  s<  /  tic  intoxication,  i.e.  a  condition  of  general 
poisoning,  due  to  absorption  of  toxins  from  some  septic  focus,  e.g.  putrefying 
blood-clot  in  the  uterus,  or  from  sloughing  or  gangrenous  foci.  In  the 
case  of  sapraemia  the  local  lesion  will  often  be  extensive,  and  the  intoxication 
wdll  disappear  rapidly  when  such  local  focus  is  removed  ;  whereas  in  septi- 
caemia (bacillaemia)  the  local  lesion  may  be  quite  small,  such  as  a  mere 
scratch. 

Diagnosis.  The  sudden  onset  may  suggest  that  one  of  the  exanthemata 
is  about  to  develop,  such  as  scarlatina,  or  measles  of  a  severe  type.  Diagnosis 
is  at  first  often  impossible,  especially  in  the  absence  of  a  local  focus  of  infec- 
tion, such  as  a  carbuncle,  an  area  of  cellulitis,  or  some  uterine  infection, 
often  of  puerperal  origin.  The  characteristic  rash  of  the  exanthemata  will 
usually  decide  the  question  in  a  few  days,  but  a  scarlatiniform  rash  is  not 
uncommon  in  cases  of  septicaemia.  In  most  instances  the  presence  of  some 
local  infective  lesion,  and  the  sudden  onset  of  severe  symptoms,  will  suggest 
the  diagnosis.  Removal  of  blood  from  a  vein  under  aseptic  precautions 
will  in  some  instances  afford  a  growth  of  the  infecting  organism  and  clinch 
the  diagno 

Treatm  nt.  The  first  step  is  to  remove  any  focus  of  infection  by  incision 
and  drainage,  amputation,  clearing  out  infective  placenta  from  the  uterus, 
&c.    The  obliteration  of  venous  channels  by  which  infection  may  escape 


PYEMIA  161 

into  the  system  is  indicated,  though  this  is  more  feasible  in  cases  of  pyaemia, 
such  as  that  arising  from  thrombosis  of  the  lateral  sinus,  than  in  true  septi- 
caemia ;  the  saphenous  veins  or  uterine  veins  may  be  obliterated  by  operation 
under  such  conditions.  General  treatment  is  specific  and  tonic.  The 
former  consists  in  administering  a  suitable  antiserum,  when  the  organism 
responsible  for  the  infection  can  be  recovered  from  the  blood,  by  cultural 
methods.  Where  the  nature  of  the  infection  is  uncertain  there  is  little 
harm  in  giving  polwalent  antistreptococcal  serum,  which  in  some  cases 
seems  to  have  a  good  effect.  The  rest  of  the  treatment  consists  in  maintain- 
ing the  patient's  strength  with  light  nourishing  diet,  milk,  eggs,  meat-juice, 
&c.  ;  moderate  amounts  of  alcohol,  such  as  port  and  burgundy,  are  advisable. 
The  amount  of  liquid  given  by  mouth  or  rectum  in  saline  infusions  should 
be  as  much  as  possible  to  maintain  the  blood  pressure  and  assist  in  the 
excretion  of  toxins  by  the  kidney.  Drugs  are  of  little  use  except  purges, 
e.g.  calomel,  in  moderation  to  promote  excretion  of  toxins.  (As  diarrhoea 
is  sometimes  a  later  symptom  of  septicaemia  purges  are  to  be  employed 
with  caution.)     Diuretics  are  also  used  with  this  intent. 

Pyaemia.  In  this  variety  of  general  infection  the  onset  is  also  sudden, 
usually  with  a  rigor,  high  fever,  sweating,  and  fall  of  temperature  to  below 
normal,  very  much  as  in  a  malarial  crisis.-  In  a  few  hours  the  rigor  is 
repeated.  The  patient  is  fairly  well  between  the  rigors  at  first,  but  soon 
begins  to  fail.  The  face  and  skin  are  pale,  and  soon  become  yellowish  in 
colour.  Wasting  and  weakness  are  soon  marked,  the  appetite  fails.  The 
breath  has  a  sweetish  odour,  and  the  tongue  is  dry  and  glazed,  later  dry. 
brown,  and  furred.  Following  a  preliminary  constipation,  diarrhoea  is 
often  troublesome  and  weakening.  Fever  is  of  the  remittent,  "  hectic  " 
varietv,  with  evening  rise  followed  by  night-sweat  and  fall  of  temperature. 
The  pulse  is  weak  and  rapid  ;  sometimes  a  bruit  over  the  praecordium  points 
to  infective  endocarditis,  or  pericarditis. 

As  the  disease  progresses  signs  of  abscess  formation  appear  in  the  lung, 
either  (1)  the  abscesses  being  small  and  multiple,  as  dyspnoea,  cyanosis 
and  crepitations  ;  or  (2)  the  abscesses  being  large  and  few,  or  single, 
as  pleural  pain  on  respiration,  associated  with  a  pleural  friction  sound, 
and  areas  of  dullness  and  loss  of  breath  sounds,  pointing  to  pleural  effusion 
and  consolidation.  The  larger  abscesses  may  burst  into  a  bronchus  and 
be  coughed  up  sometimes  with  favourable  issue,  more  often  with  aspiration 
into  other  parts  of  the  lung  and  further  spread  of  infection.  If  abscesses 
are  forming  in  the  liver  this  will  be  enlarged  and  tender,  and  jaundice  may 
be  noted.  The  spleen  may  show  similar  signs  of  affection.  Suppuration 
in  joints  is  painless  and  insidious  in  onset,  the  joints  rapidly  swelling  up, 
the  ligaments  and  cartilages  becoming  disorganized,  and  spontaneous 
dislocation  readily  occurs  if  care  be  not  taken,  especially  in  deep-seated 
joints,  such  as  the  hip.  In  addition,  areas  of  infection  and  inflammation 
occur  in  all  manner  of  situations,  e.g.  the  kidney,  prostate,  bladder,  brain, 
intermuscular  planes,  &c,  which  may  subside  or  break  down  with  abscess 
formation.     The  course  of  pyaemia  varies  greatly  ;    some  cases  are  fatal 

i  1 1 


162  \  TEXTBOOK  OF  SURGERY 

in  a  few  days,  with  but  slighl  abscess  formation,  Erom  waul  of  time  in 

which  tin1  latter  may  develop.  Such  cases  arc  closely  allied  to  septicaemia, 
and  may  be  called  septico-pyaemia  or  acute  pyaemia.  In  other  instances 
life  is  prolonged  for  weeks  or  months,  abscesses  forming  slowly  in  various 
part-  of  the  body  and.  owing  to  their  painlessness,  often  reaching  consider- 
able size  before  being  detected,  unless  very  careful  daily  inspection  be  made 
all  over  the  body.  In  these  chronic  cases  recovery  is  not  uncommon.  A 
favourite  site  of  such  abscesses,  which  are  often  only  partly  filled  with  pus 
and  feel  "  slack  "  on  palpation,  is  over  bony  prominences,  e.g.  the  sacrum. 
spine  of  the  scapula,  olecranon,  great  trochanter  of  the  femur,  and  is  due 
to  the  pressure  and  irritation  of  these  prominent  bones  just  as  in  the  produc- 
tion of  bed-sores.  This  type  of  abscess  may  well  be  termed  a  "  decubitus 
al'-.  ess."  A  certain  power  of  selection  is  shown  by  infective  organisms. 
Thus  where  pyaemia  follows  on  acute  diaphysitis  of  bone,  i.e.  an  infection 
on  the  diaphyseal  side  of  the  epiphyseal  line,  the  secondary  abscesses  often 
form  in  similar  positions  in  other  bones. 

Pyaemia  is  especially  consecutive  to  infections  in  the  neighbourhood  of 
widely  open  venous  channels,  as  in  bones.  We  may  call  attention  to  pyaemia 
following  acute  osteomyelitis  or  diaphysitis  of  long  bones,  and  necrosis  of 
the  temporal  bone  (mastoiditis)  consecutive  to  middle- ear  disease,  both 
conditions  leading  to  pyaemia  from  infective  venous  thrombosis  (of  the 
lateral  sinus  in  the  last  instance),  followed  by  pulmonary  embolism.  Another 
common  source  of  infection  is  the  uterus,  wdiere  the  veins  are  large,  and 
infection  of  remains  of  the  placenta  is  unfortunately  not  uncommon. 

Prognosis  of  pyaemia  is  always  grave  ;  nevertheless  by  careful  and, 
above  all,  by  early  treatment  many  cases  are  cured  by  surgical  measures. 

Diagnosis.  Where  the  condition  is  well  developed  diagnosis  is  easy, 
but  treatment  often  hopeless.  It  is  most  important  to  recognize  the  early 
signs  of  pyaemia.  The  occurrence  of  rigors  associated  with  some  infective 
focus,  e.g.  an  old-standing  middle-ear  disease,  a  mastoid  abscess,  or  some 
infective  uterine  condition,  is  very  suspicious  and  indicates  a  thorough 
investigation  of  the  affected  area,  in  most  instances  by  exploratory  opera- 
tion. Where  there  are  manifest  signs  in  the  lungs  and  liver,  and  marked 
constitutional  symptoms,  the  diagnosis  is  clear,  but  it  is  also  clear  that 
the  time  for  effective  curative  measures  is  drawing  to  a  close.  Thorough 
and  early  exploration  of  probable  starting-places  is  the  safest  means  of 
dealing  with  pyaemia,  before  there  has  been  time  for  many  infective  thrombi 
to  have  escaped  into  the  circulation.  This  brings  us  to  the  conclusion  that 
prophylaxis  is  the  best  method  of  all,  i.e.  such  condition  as  otitis  media 
should  not  be  allowed  to  persist  indefinitely,  but  should  be  subjected  to 
radical  treatment,  whether  operative  or  conservative,  so  that  such  possible 
foci  of  origin  for  pyaemia  are  completely  cured  or  removci  I . 

In  the  early  stages  cultivation  of  organisms  from  the  blood  may  be  of 
assistance  in  the  diagnosis. 

Treatment.     A.  In  the  first  place   further  dissemination   of  infective 
emboli  must  be  prevented  (a)  By  removal  of  the  infective  focus,  en  bloc  if 


TREATMENT  OF  PYEMIA  hi.; 

possible,  with  the  infected  venous  channels.  For  instance,  we  may  remove 
the  diaphysis  of  a  bone  which  is  the  seat  of  acute  infection,  or  amputate 
for  similar  condition  or  where  there  is  spreading  gangrene  of  an  extremity 
with  infective  thrombosis,  or  where  complete  removal  is  not  possible  care- 
fully curette  away  the  area  of  infection,  and  disinfect  the  site  remaining 
with  pure  carbolic,  as  in  cancrum  oris,  carbuncle,  &c.  (b)  By  obstructing 
the  venous  channels  whereby  the  infective  thrombi  become  disseminated, 
e.g.  by  tying  the  jugular  vein  where  there  is  thrombosis  of  the  lateral  sinus 
or  the  uterine  veins  for  puerperal  infections. 

B.  Secondly,  the  abscesses  should  be  opened  as  soon  as  they  arise,  and 
a  sharp  watch  kept  for  the  development  of  new  ones.  Where  the  abscesses 
occur  superficially  their  drainage  is  simple  ;  also  superficial  joints  if  opened 
early  and  drained  fairly  often  recover  well.  The  case  of  abscesses  in  the 
liver  or  lung  forms  a  more  difficult  problem.  When  from  the  signs  such 
abscesses  are  large,  well  localized,  and  possibly  single,  exploration  should 
be  certainly  undertaken,  but  where  such  abscesses  are  small  and  numerous 
operative  treatment  is  out  of  the  question,  since  this  will  only  depress  the 
patient  still  further. 

C.  The  general  treatment  is  similar  to  that  in  septicaemia,  maintaining 
the  strength  with  light  nutritious  diet  and  moderate  alcoholic  stimulant. 
Stimulating  drugs  for  the  heart  and  lung  as  indicated  by  local  signs,  e.g. 
digitalis,  ammonium  carbonate.  Saline  infusions,  purges  and  diuretics  in 
moderation  to  assist  in  eliminating  toxins.  Finally,  antitoxic  sera  and 
vaccines  made  from  the  organisms  found  in  the  patient's  blood  may  be  used. 

INFECTIONS   DUE  TO  SPECIAL  ORGANISMS 

A  classification  of  infections  based  partly  on  clinical,  partly  on  patho- 
logical grounds  seems  best  adapted  to  a  work  on  practical  surgery.  The 
following  groups  of  pathogenic  organisms  may  be  recognized  : 

(1)  Organisms  which  tend  to  produce  local  inflammations  and  suppura- 
tions, sometimes  leading  to  general  infections,  but  only  rarely,  or  when 
mixed  with  other  organisms  producing  rapid  destruction  or  gangrene  of 
the  tissues  (pyogenic  organisms). 

(2)  Organ'sms  which  typically  produce  severe  sloughing  and  gangrenous 
lesions. 

(3)  Organisms  acting  on  the  nervous  and  muscular  systems  by  means 
of  their  toxins. 

(4)  Organisms  of  the  streptothrix  and  allied  groups,  the  lesions  of  which 
form  a  large  part  of  the  "  infective  granulomata  "  of  older  pathology. 

(5)  Protozoal  infections. 

(G)  Fungi  and  yeasts,  which  are  chiefly  responsible  for  skin  diseases, 
e.g.  ring- worm,  favus,  thrush,  and  which  are  fully  described  in  works  on 
dermatology  and  general  medicine. 

(7)  Metazoal  infections  (chiefly  worm  diseases). 

(1)  Pyogenic  Bacterial  Infections.  The  organisms  met  with 
commonly  are  able  to  cause  local  inflammations,  and  abscess  formation 


ir, I  \    l  KYI  BOOK  OF  SURGERY 

when  inoculated  into  any  pari  of  the  body  and  under  certain  conditions 
may  spread  by  the  blood-stream  or  lymphatics  to  distant  parts,  setting  up 
metastatic  inflammations  and  producing  general  infection  of  a  septicemic 
or  pysemic  nature.  Such  organisms  are  staphylococci,  streptococci,  pneumo- 
mococci,  colon  bacillus,  &c.  Others  can  only  produce  a  local 
suppurative  Lesion  when  they  have  already  produced  a  general  infection; 
Buch  are  the  organisms  of  enteric  fever,  influenza,  plague,  and  perhaps 
glanders  should  be  included  rather  in  this  group  than  in  that  already 
described.  In  other  words,  in  this  group  the  local  pyogenic  action  is  only 
part  "t  a  general  infection.  As  has  hern  mentioned,  infection  with  any 
individual  type  of  these  organisms  produces  effects  which  can  often  he  recog- 
nized clinically  with  tolerable  accuracy,  e.g.  staphylococci  produce  well-defined 
-  streptococci  cause  cellulitis  or  erysipelas  :  still  in  many  instances 
different  organisms  produce  very  similar  lesions,  and  a  complete  diagnosis 
.an  only  be  made  by  bacteriological  methods.  Apart  from  mere  scientific 
accuracy  Buch  complete  diagnosis  is  useful  for  the  following  reasons  :  (a)  The 
production  of  vaccines  from  the  infecting  organism  may  be  useful  in  treat- 
ment. {!>)  The  prognosis  may  be  affected.  Thus  if  a  pyaemia  prove  to  be 
due  to  infection  with  glanders  the  outlook  is  very  had.  and  spread  of  infection 
is  more  to  be  feared  than  from  ordinary  pyogenic  cases,  (c)  The  recent 
work  on  Typhoid  Carriers  [i.e.  persons,  who  having  passed  through  an  acute 
k  of  enteric  fever, still  carry  in  their  persons  typhoid  organisms,  which 
are  virulent  to  others)  shows  the  importance  of  ascertaining  the  underlying 
cause  of  what  may  appear  to  he  a  simple  abscess. 

STAPHYLOCOCCAL   INFECTIONS 

The  staphylococcus  aureus  is  a  small  non-motile  sphere,  -U/u  in  diameter, 
retaining  the  stain  by  Gram's  method,  and  growing  luxuriantly  on  various 
media,  including  gelatin,  which  is  liquefied  as  growth  proceeds.  The 
growth  is  in  clumps  and  masses,  and  when  in  quantity  is  seen  to  be  of  an 
orange  colour.     Other  varieties  of  staphylococci,  known  from  their  colour 

treus  and  alhiis.  are  of  low  pathogenicity  and  occur  as  saprophytes 
in  the  mouth  and  on  the  skin.  Infection  with  the  pathogenic  staphylococcus 
results  in  the  formation  of  abscesses  in  the  skin,  subcutaneous  tissues,  and 
deep  parts,  '  .7.  boils,  carbuncles,  acute  inflammations  of  hone,  endocarditis, 
&c.  simple  acute  abscess  has  already  been  discussed  under  Suppuration. 
Bone  disease  will  be  dealt  with  in  a  later  section.  Endocarditis  is  fully 
described  in  medical  works;  suffice  it  here  to  note  that  such  acute  endo- 
carditis is  a  variety  of  septico-pyaamia.  There  remain  to  be  considered 
the  cutaneous  infections  with  staphylococcus  aureus,  viz.  boils,  carbuncles, 
and  ligneous  phlegmon. 

Boils.  These  are  the  consequence  of  an  infection  with  (in  most  cases) 
staphylococcus  aureus,  of  some  part  of  the  skin  where  the  subcutaneous 

es  are  den-,,  and  inelastic,  and  contain  hair  follicles  and  sebaceous  glands 
in  profusion.  The  orifices  of  the  latter  afford  entrance  to  the  microbe. 
'I  he  inflammation  thus  se1   up  causes  great  hypem-mia.  and  owing  to  the 


BOILS  165 

inextensibility  of  the  tissues  the  swelling  interferes  with  the  blood-supply, 
and  instead  of  the  tissues  gradually  breaking  down  with  the  formation  of 

pus  (abscess),  a  considerable  mass  of  tissues  dies  at  once,  forming  a  slough, 
the  "  core  "  of  the  boil.  The  seats  of  election  for  boils  are  tin1  nape  of  the 
neck  and  the  buttocks,  since  at  these  places  there  is  friction  to  rub  in  the 
organisms  (from  the  collar,  or  the  act  of  sitting  if  such  exercise  as  riding 
or  rowing  be  undertaken).  Moreover,  the  tissues  in  these  places  are  dense 
and  inelastic.  The  alse  of  the  nose  and  the  external  auditory  meatus  are 
also  favourite  sites  ;  here  picking  accounts  for  inoculation  of  organi.-ms. 
and  the  subcutaneous  tissues  are  especially  dense. 

Signs.  A  boil  starts  as  a  red  pimple,  usually  about  a  hair  follicle,  which 
becomes  larger,  harder,  and  extremely  tender,  while  the  underlying  and 
surrounding  tissues  feel  tense  and  infiltrated  with  oedema.  In  a  few  days 
the  apex  of  the  boil  becomes  reddish- 
purple,  and  bursts,  discharging  a  little 
pus,  and  the  slough  of  whitish-yellow 
colour  is  disclosed  in  the  centre  of 
the  boil ;  the  slough  gradually  separ- 
ates, and  the  cavity  heals  by  granula- 
tion. In  some  instances  the  process 
is  less  severe  and  the  inflammation 
subsides  before  bursting  of  the  boil 
occurs,  and  the  slough,  which  is 
smaller,  is  absorbed  by  the  surround- 
ing granulation  tissue  :  such  a  condi- 
tion is  known  as  a  "  blind  boil."  After- 
separation  of  the  slough  the  fistula  Fig.  49.  Staphylococci  (magnified).  * 
heals  rapidly,  but  fairly  often  the  in- 
fective discharge  from  the  open  boil  leads,  by  infection  of  surrounding 
follicles,  to  production  of  further  boils  in  the  vicinity  of  the  original  focus 
of  infection,  and  thus  a  crop  of  boils  springs  up  of  varying  age  and  ripeness, 
which  may  take  a  long  while  to  heal.  Where  a  boil  is  large,  or  several 
occur  together,  there  may  be  considerable  fever  and  constitutional  depres- 
sion. A  crop  of  small  boils  in  the  beard  area  is  known  as  "  sycosis  "'  :  boils 
on  the  margin  of  the  eyelid  are  known  as  *'  styes  "  or  "  hordeolum.*" 

Treatment.  In  the  case  of  smaller  boils  hot  boric  fomentations  will 
ease  the  pain  till  the  boil  bursts,  but  where  the  boil  is  large  and  very  painful 
it  is  best  to  incise  it  freely  to  permit  the  exit  of  serum,  pus,  and  slough  : 
such  treatment  will  also  relieve  the  pain  by  reducing  the  tension  of  the 
tissues.  Suction  by  means  of  Klapp's  bells  over  the  opened  boil  will  produce 
an  increased  flow  of  serum,  and  help  to  promote  healthy  reaction  on  the 
part  of  the  tissues  ;  warm  lysol  baths,  hot  fomentation,  and  irrigation  with 
hydrogen  peroxide  will  also  be  of  assistance.  Where  repeated  crops  of 
boils  follow  each  other  vaccines  are  worth  a  trial  ;  50  to  200  million  dead 
staphylococci,  obtained  for  choice  from  the  patient's  own  lesion,  are  injected 
sulx'utaneously,  and  the  dose  repeated  every   lour  days  for  a   few  d<ise<. 


A  TEXTBOOK  OF  SURGERY 

In  some  instances  healing  is  rapid  with  Buch  treatment.  \>  regards  general 
lit,-  Eoi  the  time  is  often  importanl  {i.e.  a  holiday), 
a-  boils  are  often  a  local  Bign  of  overwork  and  general  depression.  Mild 
ise  in  the  open  air.  light  bul  nutritious  diet,  mild  stimulants.  Buch 
as  burgundy,  keeping  the  bowels  regular,  and  a  tonic  of  iron  are 
advisable. 

'  lrbuncle.  This  condition  is  similar  to  that  found  in  boils,  hut  on 
a  larger  seal.-,  and  whereas  in  boils  the  infection  and  sloughing  is  confined 
to  the  skin,  in  carbuncle  it  spreads  to  the  subcutaneous  tissues,  and  the 
slough  i>  much  larger.  Also  a  carbuncle,  if  left  to  burst,  opens  on  the  surface 
vera!  openings.  The  causal  agent  is  usually  the  staphylococcus,  hut 
in  addition  there  is  some  depressed  condition  of  the  patient  as  well,  such 
,al  disease,  glycosuria,  overwork,  under-feeding.  &c.  Carbuncles  are 
uncommon  before  middle  age  and  occur  in  similar  situations  to  those  affected 
by  boils,  especially  the  nape  of  the  neck. 

Signs.  A  hard.  red.  tender  swelling  of  considerable  area  appears;  the 
patient  often  has  high  fever,  feels  very  ill.  with  thirst  and  failure  of  appetite. 
hater  the  swelling  changes  from  red  to  purple  in  colour,  and  becomes  boggy 
to  the  touch,  finally  bursting  by  several  apertures,  discharging  pus  ami 
sloughs.  Where  the  resistance  of  the  patient  is  low  the  process  of  sloughing 
may  spread,  the  openings  coalescing,  leading  to  the  formation  of  a  huge 
Bloughy  mass,  and  severe  constitutional  depression  results  ;  signs  of  general 
infection  (septicaemia,  pyaemia)  appear,  especially  if  the  carbuncle  is  on  the 
face  (which,  by  the  way,  is  an  uncommon  situation)  ;  the  patient  passes 
into  a  typhoid  state,  and  death  follows,  often  preceded  by  coma. 

Diagnosis.  From  cellulitis  (i.e.  streptococcal  cellulitis,  for  a  carbuncle  is 
pathologically  a  localised  sloughing  staphylococcal  cellulitis)  the  greater  red- 
hardness  and  localisation,  and  the  situation  of  the  swelling  on  the 
nape  of  the  neck  or  back,  will  distinguish  the  condition  of  carbuncle.  From 
a  gumma,  which  is  ready  to  burst  through  the  skin,  the  greater  constitutional 
disturbance  and  more  rapid  course  of  carbuncle  will  distinguish.  After 
irbuncle  has  burst  and  quieted  down  somewhat,  the  punched-out  ulcer 
left  is  not  at  all  unlike  that  left  by  the  bursting  of  a  large  gumma  ;  moreover. 
in  some  instances  the  formation  of  a  carbuncle  is  not  attended  with  so  much 
constitutional  disturbance  as  has  been  described  :  in  such  cases  examining 
the  mine  for  sugar  and  the    blood-serum  for  the  Wasserman  reaction  will 

In-   helpful. 

'mini.    The  general  condition  should  be  improved  ;  where  glycosuria 

•  a  very  moderate  anti-diabetic  regime  should  he  i  ust  it  ule.  I  :  in  other 
-  fresh  air.  sunlight,  generous  diet,  red  wine  and  iron  are  essential. 
Locally  the  openings,  if  present,  should  he  connected  by  a  crucial  incision  or 
the  mass  if  unbroken,  opened  in  this  manner,  the  slough  removed  with 
harp  spoon  and  the  resulting  raw  surface  painted  with  pure 
carbolic  to  prevent  the  absorption  of  infective  material,  and  dressed  with 
boric  fomentations,  [irrigation  with  peroxide  lotion  should  be  carried  out  at 
frequenl  intervals,     hater,  if  progress  is  not  favourable,  vaccine  treatment 


STREPTOCOCCAL  INFECTIONS  167 

as  for  boils,  with  organisms  obtained  from  the  patient's  own  carbuncle,  is 
worth  a  trial. 

Ligneous  Phlegmon  (Reclus).  Ligneous  or  wooden  cellulitis  is  an 
uncommon  condition  due  to  a  chronic  infection  with  staphylococci,  in  which 
is  formed  a  great  amount  of  fibrous  tissue  and  very  little  pus.  This 
condition  is  sometimes  found  around  buried  sutures  or  ligatures,  also  as  the 
result  of  infection  of  lymph  nodes  of  the  groin  or  neck.  The  condition 
presents  itself  as  hard,  tolerably  well-defined  tumour,  the  history  suggesting 
inflammation  of  a  chronic  nature.  Treatment  consists  in  carefully  dis- 
secting away  all  the  fibrous  tissue,  which  owing  to  the  presence  of  large  vessels 
(carotids,  femorals)  running  close  to  or  through  the  mass,  is  not  easy  in  many 
instances.  Vaccines  are  spoken  well  of 
in  this  connexion,  but  as  in  other  con- 
ditions their  action  is  most  uncertain. 

STREPTOCOCCAL  INFECTIONS 

The  streptococcus  pyogenes  is  a  non- 
motile  sphere  l'Oyu  in  diameter,  which 
retains  the  stain  by  Gram's  method. 
It  grows  but  scantily  on  ordinary 
media,  such  as  gelatin,  which  is  not 
liquefied,  in  chains  of  varying  length  ; 
at  times  the  chains  are  so  short  that 
the  appearance  of  diplococci  is  pre- 
sented. A  good  many  apparently  dif-  Fig..~>0.  Streptococci  in  pus  (magni fio.l). 
ferent    sorts    of    streptococci    can    be 

distinguished  by  cultural  tests,  but  it  is  quite  uncertain  whether  these  are 
permanent  species  or  temporary  variations  due  to  environment.  The 
relation  of  this  organism  to  the  diplococcus  of  pneumonia  (pneumococcus) 
seems  to  be  very  close. 

Whereas  staphylococci  tend  to  produce  circumscribed  lesions,  such  as 
abscesses  and  boils,  streptococci,  on  the  other  hand,  more  commonly  cause  dif- 
fuse inflammations,  spreading  along  lymphatics  and  tissue-spaces  and  planes, 
viz.  erysipelas,  cellulitis,  lymphangitis,  peritonitis,  meningitis.  In  addition 
general  infections,  septicaemia  and  endocarditis  are  often  due  to  this  organism. 

The  common  lesion  produced  by  the  streptococcus  is  cellulitis  and  the 
closely  allied  condition  erysipelas,  but  we  may  note  in  passing  that  the 
streptococcal  lesions  of  the  meninges  and  peritoneum  are  very  similar 
in  pathology  to  cellulitis,  consisting  as  they  do  of  spreading  (edematous 
inflammation  with  little  tendency  to  form  well-defined  abscesses.  The  latter, 
if  formed  in  these  infections,  are  not  well  circumscribed,  but  are  diffuse 
areas  of  suppuration  scattered  through  the  inflamed  areas.  Another  result 
of  streptococcal  infection  is  the  production  of  "  false  membranes  "  on 
free  surfaces,  e.g.  the  tonsils,  peritoneum,  &c. ;  such  false  membrane  are 
formed  of  coagulated  lymph  exuded  by  the  inflamed  tissues,  and  are  also 
found  very  notably  in  pneumococcal  infections. 


\  TEXTBOOK  OF  SURGER? 

Erysipelas.  This  is  an  acute  inflammation  of  the  dermis  caused  by 
infection  with  Btreptococci,  the  result  of  contamination  of  open  lesions  which 
may  be  severe  lacerated  wounds,  mere  scratches  or  imperceptible,  orot  granu- 
lating sin  fairs  smli  as  ulcns.  sinuses,  or  where  chronic  suppuration  is  in 
progress,  as  in  mastoid  disease  ot  inflammation  ot  the  accessory  sinuses  ot 
the  uose.  Whether  the  infection  ran  be  air-borne,  as  in  the  exanthemata,  is 
uncertain  ;  mos1  cases  are  almost  certainly  caused  by  contagion,  i.e.  inocu- 
lating a  raw  surface,  whether  a  scratch  or  a  granulating  wound,  with  hands, 
instruments,  towels,  &c,  contaminated  with  the  organism.  The  onset  is 
sudden  with  high  and  continued  fever,  often  an  initial  rigor.  The  infected 
area  becomes  bright  scarlet,  burns  subjectively,  feels  firm  and  tense  on 
palpation,  and  is  often  sharply  marked  off  from  the  normal  surrounding 
tissues, by  a  distinct  edge  which  is  slightly  raised  owing  to  the  oedema 
of  the  affected  skin.  This  edge  is  better  marked  where  tin- skin  is  dense  than 
where  it  is  thin  and  with  much  lax  subcutaneous  tissue,  as  in  the  scrotum  or 
eyelids. 

Microscopically  the  tissue-spaces  of  the  dermis  are  tilled  with  leucocytes, 
fluid,  and  streptococci.  The  condition  usually  subsides  in  a  few  days  with 
desquamation  of  the  epidermis.  In  more  severe  instances  the  epidermis 
may  be  raised  in  vesicles  and  bullae,  or  in  rare  cases  the  skin  may  become 
purple,  black  ami  gangrenous,  owing  to  the  blood-supply  being  interfered 
with,  from  excessive  oedema  and  thrombosis.  Where  originating  in  con- 
nexion with  a  wound  the  latter  assumes  an  inflamed,  unhealthy  appearance. 
the  edges  being  red.  swollen,  (edematous  and  exuding  thin  sero-pus.  The 
constitutional  symptoms  are  always  severe,  as  might  be  imagined  with 
fever  of  |lt|  or  mure:  in  debilitated  subjects  and  especially  alcoholics. 
delirium,  patchy  pneumonia  and  diarrhoea  are  likely  to  develop  and  render 
the  prognosis  gloomy.  Fresh  patches  of  erysipelas  may  appear  at  distant 
parts  of  the  body,  while  the  original  focus  is  subsiding.  Recurrent  attacks 
are  frequent,  infection  with  the  streptococcus  being  of  no  protection  against 
further  attacks  <>!  tin-  organism.  <  hving  to  the  ease  with  which  streptococci 
Bpread  along  tissue  spaces  and  lymphatics,  erysipelas  is  often  combined  with 
cellulitis  (infection  of  the  subcutaneous  tissues  and  intermuscular  planes), 
while  lymphangitis  and  lymphadenitis  are  common  complications.  Attacks 
of  erysipelas  last  for  from  a  few  days  to  three  or  four  weeks;  relapses  are 
common  and  the  face  is  the  part  most  commonly  affected. 

Cellulitis.  This  consists  of  a  spreading  cedematous  inflammation  of  the 
subcutaneous  areolar  tissues  and  of  the  intermuscular  fascial  planes:  it  is 
sometimes  known  as  phlegmonous  inflammation  or  phlegmon.  The  disease 
is  in  mo  lue  to  a  pure  streptococcal  infection,  but  in  the  more  severe 

i  there  may  be,  in  addition,  infect  ion  with  the  bacillus  aerogenes  capsula- 
tufi  or  the  bacillus  ol  malignant  oedema.     More  rarely  staphylococci  cause 

similar  i  onditions,  but  the  lesion  then  is  rather  of  the  nature  of  carbuncle. 

The  pathological  anatomy  is  similar  to  that  of  erysipelas,  but  the  changes 
occur  in  the  deeper  areolar  and  fascial  planes,  the  tissue-spaces  being  filled 
with  an  exudation  of  fluid,  leucocytes  and  streptococci,  which  may  break 


CELLULITIS  169 

clown  to  form  pus  or  even  end  in  the  production  of  gangrene,  especially 
where  a  mixed  infection  is  present.  As  mentioned  in  the  last  section  the 
skin  also  may  be  affected,  when  the  condition  may  be  called  cellulo- 
erysipelas. 

Signs.  Like  erysipelas,  cellulitis  usually  arises  suddenly  with  high  fever 
rigors  and  great  constitutional  depression.  The  part  affected  becomes  en- 
larged, tense,  tender  ;  later  the  skin  overlying  it  becomes  red,  shiny,  boggy, 
and  ill-defined  abscesses  may  point  and  burst  on  the  surface.  Lymphangitis 
and  lymphadenitis  are  common  complications.  In  neglected  or  debilitated 
cases  signs  of  a  general  infection  (pyaemia  or  septicaemia)  may  follow,  though 
where  the  patient  has  good  powers  of  resistance  the  process  may  become  local- 
ized, and  abscess  or  abscesses  burst  and  healing  ensue. 

Diagnosis.  Erysipelas  is  distinguished  from  simple  acute  dermatitis  by 
the  greater  constitutional  disturbance,  the  well-defined  edge  of  the  area 
affected  (due  to  the  great  oedema)  and  the  very  bright  scarlet  colour  ;  from  a 
pointing  abscess  by  the  absence  of  any  definite  tumour-mass  and  fluctuation  ; 
from  lymphangitis  by  the  linear  distribution  of  the  latter  and  the  absence  of 
thickening  of  the  skin  in  lymphangitis  ;  from  cellulitis  by  the  brighter 
redness  and  absence  of  deep-seated  swelling  and  oedema  ;  but  as  the  two 
conditions  are  often  co-existent  and  of  similar  pathology  it  is  well  to  regard 
streptococcal  infection  of  lax  tissues,  e.g.  scrotum  or  eyelids,  as  cellulo- 
erysipelas  and  treat  accordingly.  Cellulitis  will  be  at  once  recognized  by  the 
sudden  appearance  of  a  widespread  area  of  painful,  tender,  ©edematous 
swelling,  boggy  and  ill-defined  in  character,  with  severe  constitutional 
symptoms,  fever,  rigors,  delirium.  &c. 

It  should  be  noted,  however,  that  in  some  instances  constitutional  signs 
are  not  so  prominent  as  the  above  description  might  lead  the  reader  to  believe, 
at  all  events  in  the  earlier  stages.  In  some  instances  the  patient  is  able  to 
deal  with  the  infection  up  to  a  certain  point,  without  showing  signs  of  severe 
iillness.  Such  cases  need  care,  since  later  the  general  condition  may  rapidly 
become  dangerous.  This  applies  especially  to  cellulitis  of  the  neck  (Ludwig  s 
angina). 

Ligneous  or  wooden  phlegmon,  more  usually  due  to  staphylococcal  infec- 
tion, may  also  be  of  streptococcal  origin. 

Streptococcal  Infections  of  Special  Regions.  In  the  neck  the 
infection  may  affect  (a)  the  fauces,  the  mucosa  of  which  becomes  bright  red, 
(edematous  and  liable  to  slough  ;  the  condition  here  is  grave,  since  oedema  oi 
the  glottis  is  a  not  uncommon  complication  and  the  general  intoxication  is 
always  severe.  This  condition  is  sometimes  described  as  erysipelas  of  tin- 
fauces.  (6)  Cellulitis  is  likely  to  occur  in  the  cellular  tissues  of  the  neck, 
especially  from  infection  originating  in  the  floor  of  the  mouth,  and  about  the 
submaxillary  gland.  This  is  known  as  Ludwig's  angina  and  is  very  likely  to 
lead  to  oedema  of  the  glottis  and  readily  spreads  along  the  deep  cervical 
fascia  to  the  mediastinum.  These  possible  complications  and  the  fact  that 
such  cellulitis  may  commence  without  great  constitutional  disturbance, 
render  this  a  most  dangerous  condition,  for  it  has  often  reached  an  almost 


170  \  TEXTBOOK  OF  SURGERY 

bop  'ii\   before  drastic  measures  of  surgical  interference 

are  properly  carried  <>ut. 

In  tin-  scrotum  cellulo  erysipelas  is  liable  to  develop,  quite  aparl  from 
tion  of  urine,  often  leading  to  complete  sloughing  of  the  scrotum 
and  exposure  of  the  testes.     This  condition  as  well  as  cellulitis  of  the  orbit 
and  pelvis  are  described  in  tin'  sections  referring  to  these  parts. 

'.     Isolation  of  all  cases  of  streptococcal  infection,  whether  of 
the  erysipelatous  or  cellulitic  variety,  is  a  wise  precaution  on  account  of  the 
with  which  the  infection  spreads  from  one  patient  to  another. 

Erysipelas.  In  mosl  instances  this  disease  inns  a  favourable  course,  and 
natural  recovery  takes  place  just  as  in  Lobar  pneumonia.     General  treatment 

-  sts  in  confinement  to  bed,  a  ligbl  strengthening  diet,  open  bowels  and 
stimulants  (alcohol  and  strychnine),  if  signs  of  cardiac  failure  develop. 
Locally,  if  a  wound  he  present,  this  should  be  dressed  frequently  with  warm 
moist  ili  _       uli  as  boric  fomentations,  irrigation  with  weak  carbolic 

and  peroxide  of  hydrogen  lotions,  and  immersion  in  a  weak  lysol  bath  are 
also  helpful.  Where  there  is  no  wound  present  local  treatment  is  of  little 
use  except  as  a  means  of  palliation,  for  which  end  powdering  with  boric  acid 
and  starch  or  the  application  of  boric  fomentations  is  often  comforting. 

mpts  to  localize  the  infection  by  scarification  or  painting  the  sur- 
rounding  tissues  with  iodine  or  silver  nitrate  solution  are  quite  useless, 
I  it  for  cure  by  faith.  Specific  treatment  with  injections  of  antistrepto- 
coccal  serum  is  of  doubtful  value,  but  the  use  of  the  polyvalent  serum  is 
worth  a  trial  in  severe  cases,  in  case  the  requisite  strain  of  organisms  may  be 
present  in  the  anti-serum  and  thus  benefit  result. 

Cellulitis.  The  general  treatment  is  similar  to  that  of  erysipelas. 
L«m  ally,  in<'  incisions  shoidd  be  made  into  the  inflamed  area  especially  where 
the  ti-sues  are  purple,  soft  and  boggy.  The  tendency  is  to  make  these 
incisions  too  small.  In  the  limbs  incisions  for  cellulitis  should  not  be  less 
than  '21  inches  in  length,  so  that  the  skin  and  underlying  tissues  gape  freely, 
permitting  ready  exudat  ion  of  serum.  A  number  of  incisions  of  this  size  are 
made  into  the  part  affected  and  should  extend  as  deeply  as  the  infection  has 
spread.  Where  abscesses  are  present  these  may  be  drained  with  tubes  for  a 
After  being  opened  the  part  is  dressed  with  large  boric  fomenta- 
tions and  irrigated  with  peroxide  lotions,  soaked  in  baths  of  weak  lysol  or 
l']»<m  cent,  common  -alt.  lor  one  or  two  hours,  three  times  daily,  or  longer  if 
the  p, it i, - 1 1 t  can  stand  it  without  too  much  fatigue.  The  incisions  are  made 
in  the  direction  of  large  vessels,  i.e.  in  the  limbs,  along  their  axes;  tubes  should 
never  he  inserted  in  the  vicinity  of  large  vessels:  bleeding  can  usually  be 
checked  by  ligature  or  gauze  packing  and  moderate  pressure  with  dressing 
and  bandage  for  an  hour  or  so.  Where  cellulitis  continues  to  spread  in 
spite  ol  this  treatment,  or  is  assuming  a  gangrenous  type,  still  larger  incisions 
are  made  and  packed  with  gauze  soaked  in  peroxide  of  hydrogen  which  is 
changed  frequently.  In  spite  oJ  these  measures  the  infection  is  spreading,  and 
if  severe  secondary  haemorrhage  or  great  constitutional  depression  result,  am- 
putation will  sometimes  be  needed.     The  polyvalent  a  i  ^streptococcal  serum 


PNEUMOCOCCAL  INFECT TOX  171 

may  be  tried  in  bad  cases,  but  too  much  should  not  be  expected  from  this. 
The  main  point  in  the  treatment  of  cases  of  cellulitis  is  to  be  free  with 
the  knife  in  the  early  stages  and  not  merely  to  scarify  the  skin.  Later. 
when  healing,  there  will  be  a  great  production  of  fibrous  tissue  in  the  limb 
and  wasting  of  muscles,  matting  of  tendons,  &c,  needing  a  prolonged 
course  of  massage  and  movements  to  set  right,  and  here  it  is  important  to 
note  that  maintenance  of  rest  by  splinting  can  easily  be  too  prolonged. 
Early  and  slight  movement  of  the  fingers  should  be  made  long  before  healing 
has  taken  place  to  prevent  the  tendons  becoming  hopelessly  fastened  in  their 
sheaths  ;  especially  is  this  precaution  necessary  in  those  of  advancing  years. 

PNEUMOCOCCAL  INFECTION 

The  pneumococcus  of  Fraenkel  is  an  ovoid  coccus  1-0^  in  length,  staining 
by  Gram's  method,  and  often  possessing  a  capsule  of  clear  material.  These 
cocci  grow  feebly  on  culture  media 
and  do  not  liquefy  gelatin  :  they  are 
arranged  in  pairs  in  a  longitudinal 
manner  and  sometimes  in  short 
chains.  The  relation  of  this  organism 
to  the  streptococci  is  uncertain  but 
undoubtedly  close.  Besides  causing 
lobar  pneumonia,  the  pneumococcus 
is  responsible  for  other  diffuse  sup- 
purative lesions,  especially  of  serous 
membranes.  Infections  of  the  pleura, 
peritoneum,  meninges,  endocardium, 
synovial  membrane  of  joints  and  the 
middle  ear  are  often  caused  by  this  Fig.  51.  Pneumococci  in  pus  (magnified). 
organism  or  closely  related  short- 
chained  streptococci.  The  pus  produced  is  often  characteristic,  consist- 
ing of  creamy  "  laudable  "  fluid  containing  large  masses  of  coagulated 
lymph  to  a  degree  seldom  found  in  other  suppurative  infections.  The 
treatment  is  the  same  as  has  already  been  described  for  suppurative 
lesions  in  general,  and  further  mention  of  these  infections  will  be  made  in 
the  section  on  the  Pleura,  Peritoneum,  &c.  Protective  sera  and  vaccines 
have  been  made  to  cope  with  this  infection,  but  the  avail  of  these  is 
hitherto  not  very  convincing. 

INFECTION  WITH   THE   COLON  BACILLUS 

This  organism  is  a  motile  rod  2  to  8M  in  length  by  -5^  wide,  possessing 
flagella  and  not  retaining  the  stain  by  Gram's  method ;  it  grows  freely  on 
culture  media  and  produces  gas.  Many  different  strains  of  the  colon  bacillus 
have  been  discriminated  by  cultural  tests.  The  organism  is  a  normal  in- 
habitant of  the  intestine,  but  has  the  power  of  developing  its  virulence  and  of 
causing  suppurative  and  gangrenous  lesions  (either  alone  or  mixed  with  strep- 
tococci and  staphylococci  or  putrefactive  organisms  such  as  the  proteus 


172 


A  TEXTBOOK  OF  SURGERY 


bacillus),  especially  of  the  intestinal  and  urinary  tracts,  e.g.  appendicitis, 
gall-bladder  infections,  pyelitis,  cystitis,  &c. 

GONOCOCCAL  INFECTION 

Thr  gonococcus  is  a  small  uon-motile  organism  of  semicircular  outline 
occurring  typically  in  pans  which  have  thru-  flat  sides  in  contiguity,  and 
under  pathogenic  conditions  occur  in  great  number  inside  cells.  This 
asm  doea  not  retain  the  stain  by  Gram's  method  and  grows  bul  feebly 
on  ordinary  culture  media  but  in  tolerable  profusion  on blood-agar.  Infec- 
tion with  the  gonococcus  is  usually  the  result  of  sexual  congress,  and  takes 
place  in  the  urethra  of  the  male  and  the  urethra  and  cervical  canal  of 
the  female:  less  often  the  mucosa  of  the  rectum,  conjunctiva,  or  the  nose 
may  become  infected.  The  result  of  the  infection  is  a  suppurative  catarrh 
of  the  mucosa  (blenorrhcea)  with  a  discharge  of  serum  loaded  with  leucocytes 

from    the   latter,    while   the   epithelium 
becomes  loosened  ami   desquamates  in 
parts,  forming  small  ulcers.     The  des 
quamated  cells  and  leucocytes  contain 
quantities  of  the  micro-organism  which 
is  a  distinguishing  feature  of  a  specimen 
of  pus  from  an  acute  gonorrhoea.  Gonor- 
rhoea) infection  may  spread  locally  along 
the  urinary  and  genital  tracts,  produc- 
ing   in    the    male    posterior    urethritis, 
vesiculitis    prostatitis   and  epipidymo- 
orchitis  :    while  in  the  female  the  results 
are   even    more    far-reaching  from   the 
manner    in    which    the    Fallopian    tubes 
open  into  the  peritoneum. 
Endometritis  and  salpingitis  may  he  followed  by  a  spread  of  the  virus 
to  the  peritoneum  usually  leading  to  pelvic  peritonitis,  hut  occasionally  to 
ral  peritonitis.     Cystitis  may  result,  hut    is  not   common.     A   general 
spread  ol  the  organism  by  the  blood-stream,  i.e.  gonorrhoea]  septicaemia, is  not 
rare,  hut  differs  from  the  ordinary  conception  of  septicaemia  in  the  mildness 
of  the  constitutional  symptoms.     The  metastatic  inflammations  occur  mostly 
in  joints  and  fascia' (acute  (hit  foot),also  m  tendon  sheaths,  and  less  often  give 
ns''  ,"  iritis  and  sclerotitis:    quite  uncommonly  the  severe  pyaemic  mani- 
festationsol  multiple  abscesses  and   endocarditis  ensue.     The  diagnosis  is 
made  by  finding  the  organism  in  the  urethral   discharge,  assisted  by  mas- 
saging the  prostate,  employing  the  two-glass  test  (see  p.  ~«r_'.  vol.  ii)  (if  no 
obvious  gleel  is  present),and  tracing  the  joinl  and  other  metastatic  infections 
to  this  source  by  careful  attention  to  the  history. 

Treatment.  In  the  lower  genito-urinary trad  consists  in  lavage,  whether 
,,v  means  ot  the  urine  or  by  various  methods  of  irrigation,  instillation.  cV-c, 
as  described  under  Urethritis  in  the  section  on  diseases  of  the  urethra! 
Specific  treatment  with  vaccines  is  fairly  successful  where  there  are  metastatic 


l'ii;.  52.     < lonococci  (magnified). 


GLANDERS  173 

infections  of  joints  or  fasciae;  five  to  five  hundred  million  dead  organisms 
have  been  used  as  the  initial  dose.  The  question  of  prophylaxis  is  briefly 
discussed  under  Syphilis. 

INFECTIONS   DUE   TO   DUCREY'S   BACILLUS.     SOFT  SORE.     CHANCROID 

This  organism  is  a  small  non-motile  rod  of  size  1  to  2/u  by  *  5/x,  not 
staining  by  drain's  method  and  difficult  of  cultivation.  The  lesions  which 
are  caused  by  this  organism  are  often  multiple  and  occur  on  the  prepuce, 
frsenum  and  skin  of  the  penis  in  the  male,  on  the  vulva,  fourchette.  labia 
minora,  in  the  female,  but  rarely  elsewhere.  The  lesion  develops  as  a 
papule  or  vesicle  which  breaks  down  in  a  few  days  to  form  a  shallow  ulcer 
with  red  margins,  sloughy  floor,  purulent  discharge  and  little  surrounding 
induration.  If  kept  clean  such  ulcers  heal  in  about  three  wTeeks,  occasion- 
ally there  is  enlargement  of  the  inguinal  glands  which  may  suppurate,  and 
the  organism  has  been  found  pure  in  the  bubo,  rendering  it  highly  probable 
that  it  really  is  the  cause  of  the  disease,  in  many  cases  at  any  rate,  though 
other  organisms  are  also  found  fairly  often,  and  probably  some  lesions  in- 
distinguishable from  soft  sores  are  due  to  infection  with  such  organisms. 
Spread  of  this  infection  beyond  the  inguinal  glands  is  unknown. 

Treatment.  Washing  the  ulcer  with  hydrogen  peroxide  lotion,  or  paint- 
ing with  pure  carbolic  and  dusting  with  boric  powder,  if  inflamed  using  boric 
fomentations,  will  result  in  rapid  healing. 

GLANDERS 

The  infective  organism  to  which  this  disease  is  due  is  known  as  the 
Bacillus  Mallei,  and  is  about  the  samesizeasthe  tubercle  bacillus  but  thicker, 
and  neither  stains  by  Gram's  method  nor  is  acid  fast.  Its  growth  on  potato 
is  succulent  and  of  a  characteristic  chocolate-colour,  and  if  injected  into  the 
peritoneum  of  a  guinea-pig  it  causes  in  a  few  days  severe  epididymo-orchitis 
with  great  swelling  of  the  testis.  Glanders  occurs  commonly  in  the  horse 
and  ass,  while  oxen  are  immune  to  its  attacks.  In  the  horse  it  usually 
originates  as  an  inflammatory  swelling  on  the  nasal  septum,  which  soon 
breaks  down  into  foul  ulcers,  while  thickened  cord-like  lymphatics  lead 
from  the  ulcers  to  indolently  inflamed  lymphatic  glands  in  the  vicinity. 
Later  there  is  general  infection  of  the  viscera.  Glanders  may  also  originate 
as  a  local  infection  of  the  skin,  which  becomes  ulcerated,  and  thickened 
lymphatic  cords  lead  to  the  enlarged  lymphatic  nodes.  This  form  is  com- 
monly known  as  "  farcy." 

In  man  the  disease  naturally  attacks  those  who  come  much  in  contacl 
with  horses  or  who  cultivate  the  organism  in  the  laboratory,  proving  par- 
ticularly fatal  to  bacteriologists,  and  being  apparently  more  infective  when 
under  cultivation  than  when  derived  from  natural  sources.  In  man  it  may 
result  from  infection  of  an  obvious  wound  or  the  source  of  infection  may  not 
be  discoverable.  When  starting  from  a  local  focus  the  wound  appears 
inflamed,  sloughy,  and  not  at  all  inclined  to  heal,  while  thickened  lymphatics 
lead  to  the  next  group  of  enlarged  lymph  nodes. 


174  \    I  EXTBOOK  OF  SI  RGERY 

re  the  disease  has  become  generalized  as  is  usually  the  case  before  it 
is  di  whether  originating  from  an  obvious  or  undiscovered  point  of 

infection)  the  course  \  aries.     It  may  be  so  acute  as  to  kill  In  a  few  days  or  it 
may  last  for  months,  and  occasionally  recovery  takes  place. 

I  the  tcute  septicemic  form  the  patienl  becomes  rapidly  ill  with 
high  fever,  great  depression,  and  signs  of  pulmonary  congestion  or  patchy 
pneumonia.    Small  al  nay  develop  subcutaneously,  shortly  before 

death,  and  careful  bacteriological  investigation  of  the  pus  from  these  will 
d  the  uature  of  the  disease.     In  a  more  common  type  there  is,  in  addition 
to  the  fever  and  pneumonic  condition,  a  pustular  rash  scattered  over  the 
body,  not  unlike  that  of  small-pox,  many  of  the  pustules  being  umbilicated  in 
a  similar  manner.     The  pu-t  ales,  however,  are  of  less  regular  size  in  glanders, 
some  being  small  subcutaneous  abscesses,  while,  as  a  rule,  a  few  large  abscesses 
will  be  discovered  if  a  careful  Bearch  be  made  ;   in  addition  the  rash  is  more 
marked  on  the  trunk  and  limbs,  less  so  on  the  face,  the  converse  of  small- 
pox.    Examination  of  the  pus  from  the  pustules  or  abscesses  will  reveal  the 
of  infection. 
(6)  'lie-  chronic  pyemic  type  may  occur  with  or  without  discoverable 
local  lesion  ;   where  such  a  local  source  of  ingress  for  the  organism  is  present 
there  will  be  a  Bloughy,  phagedenic  ulcer  with  thickened  lymphatic  cords 
leading  to  the  enlarged  lymph  glands.     The  general  condition  is  that  of 
pyemia,  viz.  hectic  fever,  wasting,  anemia  and  the  sporadic  appearance  of 
painless,  slack  abscesses  in  the  subcutaneous  tissues  or  intermuscular 
planes.     The  nasal  mucosa  is  not  commonly  involved  in  men. 

The  chronic  pyemic  type  is  very  likely  to  be  missed  unless  the  pus  from 

'ilia  be  carefully  examined. 
Prognosis.     Acute  cases  are  always  fatal.     Recovery  is  possible  in  the 
mic  type  after  months  or  years.     It  is  said  that  50  per  cent,  of  such 
recover,  but  the  disease  may  at  any  time  become  acute  and  carry  off 
the  patient. 

Diagnosis.  In  man  this  is  made  by  growing  the  organism  on  potato,  or 
by  inoculation  of  guinea-pigs  :  injection  of  malleiu  (the  toxin  of  the  bacilli), 
though  useful  in  ho]  b  dangerous  to  be  just  ifiable  in  man. 

Iment.     Prophylaxis  consists  in  testing  horses  by  injecting  mallein 
ami  destroying  glandered  animals. 

In  man.  if  the  diagnosis  can  be  made  early,  while  the  condition  is 
.-till  local,  attempts  should  be  made,  by  curetting,  excision,  and  paint- 
ing with  pure  carbolic,  t.,  eradicate  the  disease  before  it  has  become 
generalized:    tie-   importance   of  accurate    bacteriological   examination   of 

i  unhealthy  wound-  or  sloughy  ulcers,  in    those  who  deal  with    1mm 
i-  obvious. 

Wle-re  the  condition  is  generalized  there  is  little  to  be  done  except  to 

maintain  the  strength  by  judicious  feeding,  stimulants,  opening  abscesses 

and  disc  their  interior  with  strong  antiseptics,    strict 

■on  and  destruction  of  all  discharges,  dressings,  &c,  are  particularly 

•In-  very  dangerous  infection. 


ANTHRAX  175 

Organisms  which,  while  producing  a  General  Infection,  may  also  give 
rise  to  Local  Suppurative  or  Necrotic  Lesion-. 

Of  such  we  may  instance  the  bacilli  of  enteric  fever,  of  plague  and  influenza. 
The  former  is  of  the  greater  importance  in  general  surgery.  The  places 
affected  usually  are  bones  and  joints,  leading  to  a  mild  suppuration  and 
disintegration  of  the  tissues,  and  the  results  are  important  clinically,  as 
leading  to  caries  of  the  spine,  subacute  abscesses  in  bone,  and  affections  of 
joints,  of  which  pathological  dislocation  of  the  hip  is  the  best  example.  In 
most  instances  such  local  lesions  are  due  to  mixed  infections,  but  occasionally 
the  typhoid  bacillus  is  obtained  in  pure  culture  from  them.  The  effects  of  an 
attenuated  typhoid  infection  in  producing  catarrh  of  the  bile  passages  and 
formation  of  gall-stones  is  alluded  to  in  a  later  section.     Of  other  local  effects 


Fig.  53.      Anthrax   bacilli   containing 
spores  (magnified). 


Fig.  54.     Anthrax    bacilli   in   liver 
(magnified). 


of  this  organism  we  may  call  attention  to  perforation  of  the  intestines, 
phlebitis,  pyle-phlebitis,  otitis,  empyema,  orchitis,  thyroiditis,  &c. 

(2)  Organisms  which  lead  to  Sloughing.  Necrosis  and  Gangrene. 
The  pyogenic  organisms  also  have  this  power  particularly  in  mixed  in- 
fections ;  the  organisms,  however,  to  be  described  invariably  cause  sloughing 
and  seldom  or  never  abscess  formation. 


ANTHRAX 

The  organism  causing  this  disease  produces  a  general  infection  in  cattle 
and  sheep  described  as  "  splenic  fever  "  from  the  characteristic  enlargement 
of  the  spleen  ;  in  man  it  may  produce  a  merely  local  lesion  or  become 
generalized  throughout  the  system  with  fatal  result. 

The  anthrax  bacillus  is  a  very  large  non-motile  organism,  6  to  8/u  loin? 
by  1  -2/x  wide,  retaining  the  stain  by  Gram's  method.  It  grows  luxuriantly 
in  a  wavy  manner  on  media  and,  when  conditions  are  unfavourable,  forms 
small  spores  in  the  centre  of  each  rod.  which  are  highly  resisting  to  batericidal 
agents.  Infection  of  this  organism  into  an  abrasion  of  the  skin  leads  to  the 
iormation  of  an  anthrax  or  malignant  pustule,  which  may  be  the  starting- 


17.;  \    l  EXTBOOK  OF  SURGEKY 

point  of  a  general  infection,  anthracaemia.  The  disease  especially  affects 
those  whose  occupation  leads  them  into  contacl  with  infected  animals 
or  their  products,  e.g.  Bhepherds,  veterinary  surgeons,  butchers,  hide- 
porters  and  hide-workers.  In  other  instances  the  infection  is  generalised 
from  the  first  and  ...curs  mostly  with  those  who  deal  with  infected  wool. 
whence  the  name  "  wool-sorter's  disease."  The  route  of  infection  is  usually 
into  the  lungs  by  inhalation,  seldom  by  ingestion.  For  an  account  ot  this 
condition,  which  comes  od  with  acute  congestion  and  Inflammation  ot  the 


Fio.  55.     Anthrax.     The  initial  lesion  is  on  the   lower  lip,  where  on  the  right  i> 
seen  the  centra]  slough  surrounded  by  vesicles.     The  great  oedema  of  the  f 
characteristic  ol  advanced  cases. 


lungs,  the  reader  is  referred  to  works  on   internal   medicine:    the   local 
malignant  pustule  alone  is  considered  here. 

Malignant  Pustuli  From  the  method  of  infection  the  lesion  is  most 
common  on  the  lor.  arm.  face,  neck  or  shoulder.  It  commences  as  a  red 
pimple  which  swells  rapidly  with  much  surrounding  oedema,  and  though 
not  painful  is  extremely  irritable.  In  three  to  five  days  the  centre  of  the 
l>iin])lf  is  converted  into  a  black  slough  or  eschar,  and  on  the  cedematous  red 
Burface  around  appears  a  ring  of  vesicles,  giving  a  very  characteristic  ap- 
pearance. 'I  he  organisms  are  num.  ions  in  t  he  slough  and  vesicles,  but  not 
in  the  surrounding  area  of  oedema,  which  is  often  very  great.  There  is 
moderate  fever  and  malaise  with  enlargement  and  tenderness  of  the  lymph 
nodes  in  the  drainage  area.  The  process  may  subside  at  this  point,  the 
slough  separating,  the  cedema  subsiding,  and  the  resulting  ulcer  healing  by 
granulation.  In  other  less  favourable  instances,  if  no  treatment  be  adopted, 
the  cedem  -.  the  slough  enlarges, and  signs  oi  general  infection  appear; 


MALIGNANT  (EDEMA  177 

the  fever  becomes  high  with  delirium,  while  dyspnoea,  patchy  consolidation 
of  the  lung,  and  bloody  expectoration  point  to  invasion  of  the  lung,  and 
bloody  diarrhoea  to  involvement  of  the  abdominal  viscera.  Enlargement  of 
the  spleen  and  oedema  of  the  glottis  are  also  noted  in  some  cases. 

Diagnosis.  This  can  usually  be  made  by  noting  the  black  slough,  sur- 
rounded by  vesicles,  lying  on  an  area  of  gross  oedema.  Severe  reaction  to 
accidental  vaccination  with  small-pox  vaccine,  is  not  unlike  anthrax 
pustules  in  the  oedema  and  vesicles,  but  the  slough  is  wanting  :  sometimes 
pyogenic  organisms  lead  to  somewhat  similar  lesions.  The  diagnosis  can  be 
made  rapidly  by  staining  the  films  of  the  fluid  from  the  vesicles,  and  finding 
the  organism. 

Treatment.  It  seems  generally  admitted  that  treatment  with  anti- 
anthrax  serum  alone  gives  the  best  results.  The  serum  of  Sclavo  is  made 
by  inoculating  asses  first  with  a  culture 
of  the  organism  attenuated  by  growth 
at  high  temperature,  and  later  with  less 
attenuated  virus,  and  finally  with  a  nor- 
mal virulent  culture  of  the  organism. 
40  c.c.  are  injected  in  separate  parts  of 
the  body,  10  c.c.  at  each  point,  and  if 
the  condition  is  not  regressing  the  same 
amount  is  given  after  twenty-four 
hours.  It  is  stated  that  the  results  of 
local  excision  combined  with  inocula- 
tion are  no  better  than  those  with 
serum   alone.     Thus  local   excision   is 

onlv  indicated  where  the  serum  is  not       Fig.  56.     Bacilli  of  malignant  oedema 
.,,.,.,  ■■  •  (magnified). 

obtainable  ;  in  which  case  the  necrotic 

area  with  the  surrounding  oedema  should  be  excised  and  the  raw  surface 
cauterized.  Treatment  in  severe  cases  is  on  the  general  lines  of  main- 
taining the  strength  by  suitable  feeding  and  stimulants. 

THE  BACILLUS  OF  MALIGNANT  CEDEMA 
This  organism  is  an  anaerobic  motile  rod,  3  to  5M  by  -9^,  which  does  not 
retain  the  stain  by  Gram's  method  and  forms  spores  which  produce  a  bulging 
in  the  centre  of  the  rod.  This  organism  is  occasionally  in  human  beings  the 
cause  of  acute  spreading  emphysematous  gangrene,  but  less  often  than  is 
the  next  organism  to  be  mentioned. 

THE  BACILLUS   AEROGENES   CAPSULATUS 
This  is  an  anaerobic  organism  about  the  size  of  the  anthrax  bacillus, 

which  retains  the  stain  by  Gram's  method .     It  possesses  a  capsule  and  occurs 

in  pairs  or  chains.     It  does  not  form  spores. 

This  organism  is  essentially  saprophytic  in  its  mode  of  life,  producing 

gas  in  bodies  after  death  ;  the  post-mortem  condition  known  as  "  foaming 

Jiver  "  is  due  to  the  action  of  B.  Aerogenes.     As  has  already  been  mentioned 


178 


A  TEXTBOOK  OF  SURGERY 


it  is  an  important  factor  in  the  production  of  the  condition  known  as  acute 
emphysematous  gangrene,  bu1  Beems  only  able  to  act  in  this  manner  in  the 
presence  of  other  definitely  pathogenic  organisms.  The  fact  that  this 
organism  is  an  anaerobe  i>  of  importance  in  treatment.  Five  incisions  into 
the  affected  pari  and  irrigation  with  hydrogen  peroxide  will  often  lead  to 
a  curtailing  of  this  infection  and  growth  of  the  organism  owing  to  presence 
of  oxygen.  These  gas-producing  bacilli  appear  to  follow  on  the  trail  of  the 
havoc  wrought  by  more  definitely  pathogenic  organisms  such  as  streptococci, 
and  produce  their  Lesions  on  tissues  dead  of  dying  from  the  previous  attack 
of  such  organisms.    The  toxic  effect  of  the  gas-producing  organisms  is  very 

L'le.lt. 

VINCENT'S  ORGANISMS 

Tin-'  are  (a)  long  fusiform,  anaerobic  rods.  LOyu  by  1/z,  tapering,  non- 
motile,  and  not   retaining  the  stain  by  (dam.-  method,  and  (b)  spirochetes 

of  various  kinds  which  are  motile  and 
resemble  the  Refringens  type  found  in 
chancres,  i.e.  being  larger,  more  refra  - 
tile,  and  with  fewer  curves  than  the 
spirochpeta  pallida  of  syphilis. 

Both  forms,  rods  and  spirillse,  are 
found  in  various  sloughy  ulcers  es- 
pecially about  the  mouth  and  fauces 
(Vincent's  angina),  also  in  noma,  can- 
crum  oris,  &c. 

It    seems    uncertain    whether   these 
are     actually     the     immediate     causal 
agents  or  whether  they  are  saprophytes 
in   the  already  destroyed  tissues,  pro- 
ducing effects  by  their  toxins. 
Lesions  associated   with  these  organisms  require  to  be  freely  excised  or 
curetted  and  cauterized  with  pure  carbolic  or  the  actual  cautery.     In  cases 
ticent's  angina  local  application  of  salvarsan  is  said  to  act  with  good 
effect. 

(3)  Organisms  Producing  Disease  by  the  Action-  ok  their  Toxins. 

The  best  examples  of  such  disease  are  tetanus  and  diphtheria.    Hydrophobia 

is  included  in  this  group,  although  the  organism  has  not  been  isolated,  and  it 

is  possible  that  its  action  is  by  the  growth  of  organisms  in  the  central  nervous 

:  (Negri  bodies). 

DIPHTHERIA 
The  bacillus  causing  diphtheria  (Klebs,  Loeffler)  is  about  3^  long  by 
•I„  wide,  often  irregular  in  shape,  staining  irregularly,  and  sometimes,  if 
degenerating,  Bhowing  clubbing  at  itsends.  This  organism  retains  I  he  stain 
by  Cram's  method  and  grows  fairly  well  on  culture  media,  especially-  on 
blood  serum.  The  organism  usually  infects  mucous  surfaces,  especially 
the  fauces,  Dose,  pharynx,  larynx,  and  trachea,  also  the  conjunctiva  and 


I'n..  57.     Vincent's  spindles  and 
Bpirillae  (n 


DIPHTHERIA  179 

occasionally  the  surface  of  wounds.  The  characteristic  lesion  is  a  local 
necrosis  with  oedema  of  the  surrounding  tissues  and  exudation  of  fibrin, 
which  together  with  the  necrosed  surface  material  forms  a  "  false  membrane," 
on  removal  of  which  a  raw,  bleeding  surface  remains. 

From  a  surgical  standpoint  the  action  of  diphtheria  is  chiefly  mechanical, 
causing  an  obstruction  of  the  larynx  and  trachea  owing  to  the  presence  of 
this  "  false  membrane  "  and  the  accompanying  oedema,  which  produce  the 
signs  of  "  laryngeal  obstruction  "  necessitating  tracheotomy  or  intubation 
as  described  under  affections  of  the  larynx.  The  more  wide-reaching  effects 
of  the  diphtheria  bacillus,  due  to  the  action  of  its  toxins,  are  discussed  in  works 
on  Internal  Medicine  and  need  only  a  brief  mention  here.  The  diphtheria 
toxin  specially  affects  nerves  producing  paralysis  (consecutive  to  neuritis), 
which  may  affect  the  nerves  supplying  such  important  muscles  as  the 
diaphragm  as  well  as  those  of  the  palate,  pharynx,  the  oculomotor  nerves, 
and  those  of  the  limbs,  especially  of  the  legs.  Other  toxins  may  affect  tissues 
directly,  e.g.  the  heart  may  fail  from  the  action  of  one  toxin,  while  others 
again  are  responsible  for  the  fever,  sloughing,  &c. 

Diagnosis.  This  is  made  by  examination  of  cultures  on  blood  serum  from 
the  affected  part,  and  from  the  staining  reactions  ;  but  diphtheria  antitoxin 
should  be  given  to  all  cases  which  show  clinically  a  membranous  tonsillo- 
pharyngitis  or  a  foul  fibrinous  rhinitis,  without  waiting  to  corroborate  the 
diagnosis  by  bacteriological  measures,  since  saving  twenty-four  hours  in  this 
disease  may  mean  a  lot  to  the  patient. 

Treatment.  The  cure  of  diphtheria  by  means  of  antitoxin  is  one  of  the 
most  successful  practical  applications  of  bacteriology,  and  the  success  is 
largely  because  diphtheria  can  be  diagnosed  early,  from  the  local  lesion, 
before  the  neurotoxins  have  combined  with  the  tissues  and  produced  much 
effect.  This  is  very  different  from  the  state  of  affairs  in  tetanus,  where  the 
local  lesion  is  often  inconspicuous  and  the  diagnosis  is  never  made  till  the 
toxins  have  firmly  combined  with  the  tissues  of  the  nervous  system  to 
produce  the  clinical  picture  of  the  disease,  and  are  by  this  time  almost 
impossible  to  remove  from  their  combination.  It  is  important  to  recognize 
the  possibility  of  diphtherial  infection  of  a  wound  which  is  not  healing  well, 
and  shows  a  sloughy,  membranous  surface,  since  it  may  otherwise  be  hard 
to  understand  the  later  development  of  paralyses  following  a  wound  which 
has  not  healed  by  first  intention  ;  moreover  if  the  diagnosis  of  such  infection 
of  a  wound  is  made  by  bacteriological  investigation  and  antitoxin  be  given, 
such  consequences  (paralyses)  may  often  be  avoided.  This  is  another 
example  of  the  importance  of  absolute  correctness  of  diagnosis  not  only 
from  the  clinical  but  also  the  bacteriological  aspect.  Where  diphtheria  is 
diagnosed  or  suspected  strongly  on  clinical  grounds,  4CXX)  units  of  diphtheria 
antitoxin  should  be  given  as  soon  as  possible  while  the  diagnosis  is  being  con- 
firmed ;  the  dose  may  be  repeated  on  the  following  day  if  the  improvement 
is  not  adequate. 


A  TEXTBOOK  OF  SlROERY 


TETANUS 
The  infective  agent  in  this  disease  is  an  anaeiobic  motile  bacillus,  4^ 
long  by  •!,(  wide,  Btaining  by  Gram's  met  hod  and  forming  spores  which  are 
Been  as  well-marked,  rounded  swellings  at  one  end  of  the  rod,  giving  the 
characteristic  appearance  of  a  "  drumstick."  The  specific  action  of  the 
bacillus  is  produced  by  the  action  of  its  toxins,  which  are  absorbed  along  the 
nerve  trunks,  thus  reaching  the  spinal  cord  and  medulla.  The  organism 
has  little  if  any  power  of  growing  on  living  tissues,  but  rather  grows  on 
tissues  already  destroyed  by  the  action  of  other  organisms  (e.g.  some  of  the 
pyogenic  group),  or  in  foreign  bodies  which  have  been  imbedded  in  the  tissues : 
this  explains  the  fact  that  tetanus  most  commonly  results  after  badly  lacer- 
ated and  fouled  wounds,  compound  fractures,  &c.   Tetanus  toxin  is  perhaps 

the  most  lethal  substance  known ;  the 
fatal  dose  is  estimated  at  about  -2  of 
a  milligram,  and  thus  infection  with 
quite  a  small  mass  of  the  bacteria,  even 
if  they  do  not  increase  in  number  in  the 
wound,  wall  readily  result  in  a  fatal 
termination.  The  tetanus  bacillus  is 
a  normal  inhabitant  of  garden-earth 
and  where  putrefaction  is  taking 
place,  as  in  dunghills  and  ground 
about  stables  ;  it  also  is  more  prevalent 
in  hot  climates.  This  disease  is  a 
good  example  of  what  has  already 
been  described  as  a  sapraemia  or 
intoxication. 

Course.  The  signs  of  tetanus  appear  as  early  as  three  days  or  not  till 
after  as  many  weeks  after  infection.  There  may  be  no  obvious  wound  as 
a  ,-ource  of  entry.  If  a  wound  be  present  it  may  be  a  quite  small  sup- 
purating focus  or  a  sloughing  lacerated  wound  of  large  size  ;  foreign  bodies 
are  often  imbedded  in  such  wounds.  Clinically  the  essential  features  of  this 
disease  are  tonic  or  constant  rigidity  of  the  muscles  with  exacerbations  in 
the  form  ol  spasms  or  cramps,  which  are  also  of  a  tonic  character,  i.e.  steady 
prolonged  muscular  contraction  without  jerking.  The  rigidity  begins  in 
the  neck  and  muscles  of  mastication.  There  is  slight  difficulty  in  opening 
the  mouth,  and  the  neck  feels  rather  stiff,  features  which  are  likely  at  first 
to  he  attributed  to  catching  cold,  muscular  rheumatism,  &c.  ;  but  the 
occurrence  of  painful  spasms  occurring  at  intervals  suggests  the  advent  of 
tie-  more  serious  disease.  The  rigidity  gradually  spreads  to  the  muscles 
of  the  trunk,  the  erector  spinas  being  specially  affected.  Usually  the  trunk 
hed  backwards  in  a  position  of  lordosis  (opisthotonos).  Lateral  bending 
(pleurotonos)  and  forward  bending  (emprosthotonos)  of  the  body  are  also 
described,  Inn  these  conditions  are  rare.  The  facial  muscles  are  affected 
early,  giving  the  face  a  set.  mask-like  expression,  with  occasional  spasms 


Fio. 


58.    Tetanus  bacilli  with  terminal 
spores  (magnified). 


TETANUS  181 

affecting  particularly  the  lower  portion,  giving  the  effect  of  a  fleeting  and 
ghastly  smile,  the  well-known  "  risus  sardonicus."  Spasm  of  the  limbs 
occurs  later  and  then  affects  little  more  t  han  those  muscles  attaching  the 
limbs  to  the  trunks,  such  as  the  glutei,  which  help  in  producing  the  arching 
of  the  back,  the  latissimi  dorsi  which  drag  the  arms  backward  ;  the  small 
muscles  of  the  hands  are  unaffected. 

Affection  of  the  muscles  of  respiration  is  variable  but  highly  important, 
whether  involving  the  diaphragm  and  other  inspiratory  muscles  or  the  in- 
trinsic muscles  of  the  larynx,  and  leading  to  spasm  of  the  glottis.  In 
either  case  sudden  death  may  result  from  respiratory  cessation,  owing 
to  spasm.  From  the  severity  of  the  spasms,  rupture  of  the  contracting 
muscles  is  not  uncommon.  The  spasmodic  exacerbations  vary  in  intensity 
and  frequency,  being  worse  where  a  fatal  result  is  likely  and  are  increased 
by  external  stimuli,  such  as  loud  noises,  bright  lights,  moving  the  patient,  &c. 

As  regards  the  general  state,  the  mind  is  clear,  the  patient  being  in  con- 
stant fear  of  the  commencement  of  fresh  spasm.  The  temperature  is  at 
first  normal  but  fever  becomes  marked,  as  the  disease  proceeds,  and  towards 
a  fatal  termination  hyperpyrexia  is  common,  the  temperature  sometimes 
rising  for  a  short  time  after  death.  Profuse  sweats  and  marked  constipation 
are  usual. 

The  course  varies ;  the  spasms  may  become  more  frequent  and  more 
severe  till  the  patient  dies  of  exhaustion  or  sudden  respiratory  spasm  ;  or 
the  exacerbations  become  less  numerous  and  of  less  severity,  till  they  gradu- 
ally cease,  taking  about  three  weeks  to  do  so  completely.  As  the  spasms 
diminish  the  tonic  rigidity  of  the  muscles  becomes  less  marked,  but  at  any 
time  there  is  the  chance  of  a  severe  attack  of  respiratory  spasm  carrying  off 
the  patient. 

Vakieties  of  Tetanus.  Several  divisions  are  made,  e.g.  into  acute  and 
chronic.  There  is,  however,  no  sharp  line  of  distinction  between  these 
varieties  ;  the  rapidity  of  onset  after  infection,  the  magnitude  and  frequency 
of  the  spasms,  are  the  distinguishing  features. 

Tetanus  neonatorum  from  infection  of  the  umbilical  cord  in  new-born 
infants  differs  in  no  way  from  the  disease  in  adults. 

Head-tetanus  or  cephalic  tetanus  is  an  important  variety  from  the 
possibility  of  errors  in  diagnosis.  In  this  variety,  in  addition  to  the  spasm  of 
the  muscles  of  the  neck  and  of  mastication,  there  is  facial  paralysis  which 
in  most  instances  is  unilateral.  This  facial  paralysis  is  supposed  to  be  due 
to  the  absorption  of  tetanus  virus  producing  a  neuritis  of  the  facial  nerve, 
and  that  this  causes  a  swelling  of  the  latter  as  it  passes  through  the  bony 
Aqueduct  of  Sylvius  with  resulting  paralysis  from  pressure.  In  these  cases 
the  point  of  infection  is  somewhere  on  the  face  or  neck.  The  muscles  of 
deglutition  are  sometimes  paralysed  as  well  as  those  of  facial  expression,  and 
the  resulting  difficulty  in  swallowing  has  given  this  condition  the  further 
synonym  of  "  tetanus  hydrophobics. "  The  prognosis  of  this  form  is  good 
if  the  affection  remains  confined  to  the  head,  but  if  it  spreads  to  the  trunk 
most  cases  die.     In  the  early  stage  head-tetanus  may  be  mistaken  for  simple 


182  \  TEXTBOOK  OF  SURGERY 

facia]  paralysis  ;  the  rigidity  of  the  jaw  and  neck  should,  if  care  be  exercised, 
help  in  avoiding  such  serious  error. 

p  ,  ?<  This  is  always  grave,  varying  with  the  rapidity  of  onsetafter 
infection  and  the  severity  of  the  convulsions.  If  originating  within  10 
days  of  infection  recovery  is  rare,  and  the  longer  the  patient  survives  the 
better  the  prognosis  becon 

Diagrm  is.  Tetanus  is  not  likely  to  be  confused  with  strychnine  poisoning 
except  in  books.  Thefact,  that  incase  of  strychnine  poisoning,  the  muscles 
arc  flaccid  betweeu  the  spasms  and  those  of  the  limbs  are  specially  affected, 
while  in  tetanus,  in  addition  to  spasms,  there  is  the  constant  tonic  rigidity 
affecting  the  facial  and  masticatory  muscles  and  those  of  the  neck  and  back, 
will  help  in  readily  discriminating. 

In  hydrophobia  the  spasms  are  "  clonic  "  or  jerking,  and  not  tonic  in 
character,  and  a  fleet  the  muscles  of  deglutition  and  respiration  only,  and  not 
those  of  the  jaw,  neck  and  spine,  while  in  addition  hallucinations  are  generally 

nt  in  hydrophobia  ;  other  differences  have  been  mentioned  under  Head- 
Tetanus. 

In  meningitis  there  is  a  similar  rigidity  of  the  muscles  of  the  neck  and 
l»a<k.  but  in  addition  there  is  high  fever  from  the  commencement,  delirium 
and  mental  derangement,  usually  vomiting,  while  the  muscles  of  mastication, 
facial  expression  and  respiration  are  not  affected. 

Treatment.  Once  the  clinical  signs  are  manifest  the  administration  of 
a  tetanus  antitoxin  is  disappointing,  but  should  always  be  employed.  Serum 
therapy  is  less  beneficial  in  this  disease  than  in  diphtheria,  since  in  tetanus 
the  toxins  have  had  already  some  time  to  act,  as  the  diagnosis  is  only  made 
when  clinical  signs  show  that  the  toxins  have  already  combined  with  the 
tissues  of  the  nervous  system.  As  the  toxin  acts  on  the  motor-cells  of  the 
spinal  cord  and  medulla  it  seems  reasonable  to  give  part  of  the  antitoxin  by 
injection  into  the  spinal  theca  (lumbar  puncture),  partly  into  the  veins  and 
partly  subcutaneously.  (Injection  direct  into  the  brain  is  a  risky  proceeding 
and  likely  to  destroy  brain  tissue.)  100  c.c.  should  be  given  in  doses  of 
21 >  c.c.  in  various  parts  of  the  body  within  twenty-four  hours  of  the  onset  of 
symptoms.     Early  diagnosis  is  most  important. 

Local  measures  consist  in  excising,  amputating  or  curetting  and  car- 
bolizing  any  probable  focus  of  infection,  the  severity  of  the  local  treatment 
varying  with  the  size  of  the  lesion.  Thus  a  severe  lacerated  wound  or  com- 
pound fracture  demands  amputation,  while  a  small  suppurative  focus 
might  well  be  excised.  Ceneral  measures  consist  in  avoiding  all  stimuli  likely 
to  start  reflex  muscular  spasms,  by  keeping  the  patient  isolated  in  a  darkened 
room  under  the  influence  of  hypnotics,  such  as  bromides,  chloral,  chloretone, 
morphia, &c, which  should  be  given  freely.  Chloroform  may  be  administered 
for  hours  together  when  the  spasms  become  very  violent  and  frequent, 
ach  active  treatment  will,  however,  usually  perish.  The 
bowels  should  be  kept  freely  open  and  diuretics  employed  to  assist  in  the 
elimination  of  toxins.  Nerve  blocking  by  intradural  injection  of  magnesium 
sulphate  and  other  drugs  (by  lumbar  puncture)  has  been  advocated,  but 


HYDROPHOBIA  183 

unfortunately  the  most  important  part  to  be  reached  is  the  medulla  which 
contains  the  respiratory  centre  ;  and  if  this  part  was  effectively  blocked  the 
danger  would  be  no  less  than  that  of  the  over-stimulation  occurring  from 
the  disease  itself. 

Prophylaxis.  It  seems  reasonable  to  give  cases  of  badly  lacerated  and 
fouled  wounds,  which  are  suppurating,  doses  of  antitetanic  serum,  up  to 
50  c.c,  with  a  view  of  neutralizing  the  toxins  before  they  reach  the  nervous 
system.  Unfortunately  it  is  impossible  to  ascertain  what  cases  are  saved  by 
such  measures,  unless  a  very  careful  examination  be  made  for  organisms  in  the 
discharge  from  the  wound  in  these  cases. 

HYDROPHOBIA   OR  RABIES 

This  disease  is  communicated  to  man  from  carnivorous  animals,  such  as 
dogs,  cats,  wolves,  usually  by  biting,  sometimes  by  contact  of  the  saliva 
of  an  infected  animal  with  some  raw  surface  on  the  patient.  The  causative 
organism  has  not  been  isolated  or  even  seen,  unless  the  bodies  discovered 
by  Negri  are  in  fact  parasites. 

A  dog  affected  with  rabies  becomes,  within  three  to  six  weeks  of  infection, 
dull,  irritable,  morose,  and  sulks  alone  in  corners.  Later  the  animal  becomes 
furious,  charging  and  biting  at  surrounding  objects  whether  living  or  inani- 
mate. The  mouth  is  filled  with  thick,  ropy  saliva  which  renders  deglutition 
difficult.  This  stage  passes  after  a  few  hours  or  days  into  one  of  paralysis 
ending  in  death.  The  whole  course  of  the  disease  lasts  about  a  week,  and  in 
some  instances  the  paralytic  stage  supervenes  on  that  of  depression  without 
the  raging  interval.     This  variety  is  described  as  dumb  rabies. 

In  man  the  period  of  incubation  is  three  weeks  to  six  months,  the  average 
being  six  weeks.  There  is  mental  irritability,  restlessness  and  insomnia, 
together  with  difficulty  of  swallowing,  associated  with  clonic  spasms  of  the 
muscles  of  deglutition  and  a  secretion  of  thick  viscid  saliva.  These  clonic 
spasms  are  aggravated  reflexly  by  stimuli  such  as  noises,  bright  lights,  &c. 
Fever  is  usual  and  the  pulse  small  and  rapid.  The  mind  may  be  clear  but 
terrifying  hallucinations  are  common.  Death  from  paralysis  and  coma  is 
invariable. 

Pathology.  On  post-mortem  microscopic  examination  changes  are  found 
in  the  cells  of  the  medulla,  cerebellum  and  especially  the  hippocampus. 
These  consist  of  rounded  or  angular  patches  of  varying  size  which  stain 
with  eosin,  contained  inside  the  larger  ganglion  cells.  It  is  not  certain 
whether  these  "  Negri  bodies  "  are  protozoa,  or  the  results  of  cell  degenera- 
tion, but  discovery  of  their  presence  is  most  valuable  in  the  diagnosis  of 
rabies  in  animals. 

The  clinical  diagnosis  has  been  considered  under  Tetanus. 

Treatment.  Since  if  once  the  disease  develops  it  is  always  fatal,  early 
measures  and  early  diagnosis  are  needed.  As  regards  prophylaxis,  destruc- 
tion of  infected  dogs  and  general  muzzling  in  former  years  has  practically 
stamped  out  the  disease  in  this  country.  In  cases  where  a  patient  has  been 
bitten  by  a  raging  dog  the  wound  should  be  cauterized  and  the  dog  caught 


1M  \  TEXTBOOK  OF  SURGERT 

-  ertaiii  it'  it  really  had  rabies  or  not.  This  may  besettled  by  observing 
the  fair  of  the  dog,  or  better,  according  to  modern  authorities,  by  killing  the 
dog  and  having  the  central  nervous  Bystem  examined  by  an  expert  for  the 
presence  ot  Negri  bodies. 

\\  here  the  diagnosis  is  certain  from  such  examination.,  or  where  there 
i>  considerable  suspicion,  but, owing  to  the  escape  of  the  animal,  the  matter 
cannot  It  proved,  the  patient  should  be  at  once  sent  to  the  nearest  Pasteur 
Institute  tor  protective  inoculation,  since  if  this  is  done  early  immunity 
can  be  developed  before  the  disease  has  time  to  commence. 

Pasteur  found  that  immunity  could  be  produced  by  inoculating  animals 
with  emulsions  of  the  spinal  cord  of  animals  which  have  died  of  rabies; 
such  ioid-  being  dried  for  varying  periods  to  diminish  the  virulence  of  the 
infection.  Inoculation  is  performed  with  such  an  attenuated  virus  followed 
by  further  daily  injections  of  gradually  stronger  viruses.  In  this  manner 
immunity  tan  be  established  in  about  ten  days.  Now.  since  the  incubation 
of  the  disease  is  at  hast  three  weeks  there  will  be  ample  time  for  immunity 
to  be  well  developed  before  the  disease  can  begin,  if  only  the  patient  is 
brought  under  the  influence  of  the  vaccine  treatment  sufficiently  early  ;  hence 
the  great  importance  of  making  certain  by  inoculating  all  certain  or  highly 
suspicious  cases  at  the  earliest  moment. 

(4)  INFECTIONS  WITH  STREPTOTHRICES  OR  MYCO-BACTERIA 
The  organisms  of  the  streptothrix  group  are  allied  to  the  moulds,  and 
according  to  recent  investigations  the  tubercle  bacillus  should  be  included 
in  this  group,  as  well  as  other  acid-fast  bacteria  and  the  ray-fungus  with  its 
congeners.  The  lesions  of  the  pathogenic  members  of  the  streptothrix 
group  are  very  similar,  consisting  in  the  production  of  granulation  tissue, 
which  may  break  down,  with  the  formation  of  cold  abscesses  or  become 
fibrosed,  or  calcified.  In  the  cellular  conception  of  diseases  Virchow  in- 
cluded the  lesions  of  these  organisms,  as  well  as  those  of  the  spirochete  of 
syphilis,  under  the  term  Infective  Granulomata. 

A.     TUBERCULOSIS 

The  t  ubercle  bacillus  is  a  small  non-motile  rod,  3^  long  by  -3^  in  width, 
growing  very  slowly  on  cult  are  media,  of  which  glycerine-agarismost  suitable. 
Growth  of  this  organism,  although  slow,  is  abundant  when  it  takes  place. 

A 1. errant  types  of  the  bacillus  have  lately  been  described,  including 
granules,  club-like,  and  even  mycelial  forms,  showing  its  close  relation 
to  the  other  myco-bacteria.  Several  varieties  of  tubercle  bacilli  are  de- 
scribed, including  the  human,  bovine  (in  cattle),  avian  (in  birds),  the  piscine 
(in  fishes). 

The  only  classically  important  varieties  as  far  as  is  known  are  the  human 
and  bovine  types  ;  for  it  appears  that  although  human  tubercle  bacilli 
have  little  effect  on  cattle,  ye1  the  bovine  type  can  produce  extensive  lesions 
in  the  human  subject,  especially  in  bones,  joints,  glands  ;  i.e.  the  affections 
to  w  huh  children  are  prone.     The  bovine  bacillus  is  rather  shorter  and  thicker 


TUBERCLE  BACILLI  185 

than  the  human  variety,  grows  differently  on  culture  media,  and  in  addition 
seems  to  cause  a  milder  type  of  infection  in  the  human  patients  than  does  the 
human  type  of  the  bacillus.  The  difficulty  in  denning  the  bacillus  by 
staining  reagents,  which  was  overcome  by  the  patient  work  of  Koch,  is  due 
to  the  fact  that  it  can  only  be  stained  by  powerful  and  highly  mordanted 
stains,  applied  in  a  boiling  solution,  or  for  many  hours.  The  well-known 
Ziehl-Neelsen  method  is  the  best  for  common  use. 

Acid-fast  Bacilli.  The  great  feature  of  tubercle  bacilli  is  that 
when  stained  with  boiling  carbol-fuchsin  they  resist  decolorizing  with 
25  per  cent,  sulphuric  acid,  for  which  reason  they  are  said  to  be  "  acid-fast." 
Other  bacilli  having  this  property  are  those  of  leprosy  and  the  bacilli  found 
in  smegna.  The  latter  can,  however,  be  decolorized  by  the  application  of 
alcohol  following  that  of  sulphuric  acid ;  while  the  tubercle  bacillus  still 
retains  the  stain  under  such  conditions 
and  can  thus  be  distinguished.  There 
are  also  other  acid-fast  but  non-patho- 
genic bacteria  resembling,  in  micro- 
scopic appearance,  the  tubercle  bacillus, 
but  differing  in  the  appearance  of  cul- 
tures, such  as  the  bacillus  of  Timothy- 
grass  and  certain  varieties  found  in 
butter. 

The  tubercle  bacillus  is  readily  de- 
stroyed by  boiling  or  even  heating  up 
to  70°  C.  or  by  immersion  in  carbolic 
acid  solution  5  per  cent.,  in  less  than 
a  minute.  In  the  dry  condition,  how-  fig>  59.  Tubercle  bacilli  (magnified). 
ever,  the  bacilli  can  remain  alive  for 

months  and  are  not  destroyed  by  the  growth  of  putrefactive  organisms 
in  their  vicinity,  as  happens  to  many  other  pathogenic  organisms.  These 
bacilli  do  not  form  spores  unless  the  granules  described  are  such,  but  as  they 
do  not  resist  heat  they  are  unlikely  to  be  of  this  nature. 

Modes  of  Infection.  Tuberculosis  is  but  rarely  inoculated  into  the 
skin  ;  the  condition  known  as  butcher's  or  anatomist's  wart,  which  is  some- 
times associated  with  tuberculous  lymphangitis  and  lymphadenitis,  is  the 
best-known  example.  Lupus  vulgaris  perhaps  sometimes  originates  in  this 
manner. 

The  common  seats  of  infection  are  the  respiratory  and  digestive  tracts. 
Inhalation  of  dried  bacilli  mixed  with  dust  into  the  lung  leads  to  their  distri- 
bution by  the  lymphatics  to  the  bronchial  glands,  where  the  typical  lesions 
due  to  the  tubercle  bacillus  frequently  occur.  Such  infection  is  probably, 
in  most  instances,  with  the  bacillus  of  the  human  variety,  and  the  danger  of 
infection  is  much  increased  by  promiscuous  expectoration  ;  since  dried  bacilli 
are  readily  disseminated  in  dust  (dust  infection),  and  as  has  been  men- 
tioned, maintaining  a  virulent  state  for  long  periods,  while  in  a  dry  condition. 
In  the  digestive  tract  the  invasion  may  occur  through  the  tonsils  and 


186  \  TEXTBOOK  OF  SURGERY 

adenoid  tissue  ol  the  nasopharynx  into  the  cervical  glands,  or  through  the 
intestinal  mucosa  into  the  lymph-nodes  of  the  mesentery  particularly  about 
theccecum.  These  are  probably  the  two  main  points  of  entry  in  children  and 
the  bacilli  arc  in  such  case  often  of  the  bovine  type.  The  fact  thai  infection 
with  the  bovine  type  <>i  bacilli  is  more  common  in  young  subjects,  whose 
diet  is  often  principally  cow's  milk,  points  to  an  entrance  of  bacilli  through 
the  digestive  tract  and  the  greal  importance  of  a  pure  milk  supply.  From 
these  primary  seats  of  infection  the  bacilli  in  suitable  eases  spread  to  organs 
Mich  as  bones,  joints,  peritoneum,  kidneys,  testis,  brain,  &c,  both  by  lymph- 
and  blood-streams.  In  other  words,  a  very  large  number  of  tuberculous  foci 
met  with  in  Burgical  practice  are,  although  appearing  to  be  primary,  really 
secondary  to  Borne  obscure  and  almost  obsolete  focus  in  the  bronchial,  cervi- 
cal or  mesenteric  glands.     These  points  lead  us  to  various  conclusions. 

(1)  The  relatively  benign  course  of  tuberculosis  in  many  instances. 
when  affecting  joints  or  glands  in  children,  may  be  due  to  the  infection  being 
of  the  bovine  type  ;  more  rapidly  advancing  lesions  suggest  that  the  human 
type  is  responsible,  but  nothing  definite  can  be  stated  on  this  point. 

(2)  The  initial  lesion,  e.g.  in  the  bronchial  glands,  may  remain  long 
latent  and  quite  unsuspected.  In  most  instances  the  obvious  tuberculous 
focus  is  a  secondary  development. 

The  importance  in  prophylaxis  of  a  pure  supply  of  milk  and  other 
food,  avoiding  dust  and  expectoration  :  further,  in  removing  places  in  the 
body  Buitable  for  inoculation  with,  or  which  have  already  become  primary 
centres  of  tuberculosis.  The  first  group  includes  enlarged  tonsils  and  adenoid 
•ns  :  the  latter,  tuberculous  glands  of  the  neck  and  occasionally  of 
the  intestinal  tract  when  discovered  at  a  laparotomy. 

Predisposing  Causes.  Although  most  persons  are  repeatedly  exposed 
to  infection,  only  a  small  proportion  become  obviously  infected.  Many 
more,  however,  show  on  post-mortem  examination  signs  of  having  been 
ked  at  some  previous  time,  and  having  undergone  a  natural  cure,  as  evi- 
denced by  old  pleural  adhesions,  calcification  of  glands  and  lung  apices,  &c. 
('/)  'I  here  ie  a  natural  susceptibility  to  the  infection  depending  on  the  inborn 
constitution  of  the  patient  about  which  we  know  nothing,  but  which  explains 
•me  degree  the  hereditary  nature  of  the  disease  in  many  instances.  A 
proclivity  to  infection  with  the  tubercle  bacillus  is  inherited  just  as  is  one  for 
L'ont  or  rheumatism.  Sometimes  this  tendency  is  associated  with  a  general 
weakness  and  lack  of  tone  of  the  body,  but  is  not  at  all  uncommon  in  those 
ol  robust  and  even  athletic  proportions. 

(6)  External  and  preventible  causes  tending  to  increase  susceptibility 

to  infection  with  tubercle  are  (1)  Malnutrition  whether  from  deficient  food 

essive disease  such  as  syphilis,  influenza, enteric ;  overworkand 

me  instances  of  importance. 

(2)  I  ofection  w[th  large  doses  of  the  bacilli,  as  in  persons  working 

1,1  *'  where  uncontrolled  expectoration  of  those  who  are 

already  infected  is  permitted.     The  division  of  tuberculous  persons  into 

'  he  sanguine  and  phlegmatic,  is  purely  fanciful  and  may  be  summed 


ANATOMY  OF  TUBERCULOSIS  187 

up  by  saying  that  even  as  the  sun  shines  on  the  just  and  on  the  unjust  so 
neither  the  ugly  nor  the  beautiful  are  immune  to  the  inroads  of  the  tubercle 
bacillus.  Apparent  delicacy  is  no  proof  of  a  predisposition  to  tuberculosis 
nor  does  the  converse  hold  good. 

Anatomy.  The  result  of  infection  with  the  tubercle  bacillus  is  a  sub- 
acute or  chronic  inflammation  with  the  production  of  granulation  tissue, 
which  may  assume  dimensions  large  enough  to  justify  the  name  of  Granuloma 
or  granulation  tissue  tumour.  At  the  commencement  of  infection  these  results 
are  always  localized  in  small,  rounded,  discrete  areas,  which  are  described  as 
miliary  tubercles.  A 
single  tubercle  is 
tiny  granuloma  and 
may  be  regarded  as  the 
anatomical  or  biologi 
cal  unit  of  tuberculosis. 
The-  process  of  forma- 
tion of  a  tubercle  is 
like  that  subacute  in- 
flammation elsewhere. 
Around  the  tubercle 
bacilli  lodged  in  the 
tissue  there  is  hypere- 
mia, and  an  exudation 
of  round  cells  quickly 
forms.  The  origin  of 
these  cells  is  uncertain, 
but  they  are  not  poly- 
morphonuclear    leuco-  * 

-.  ..,  Fig.  60.     Tuberculosis  of  the  kidney  showing  giant  cells 

cytes,   and    are    either  (magnified). 

cells  of  the  tissue  itself, 

or  lymphocytes,  or  a  mixture  of  these.  In  addition  to  the  small  round  cells 
there  are  also  congregated  together,  especially  in  the  centre  of  the  area  affected, 
larger  cells  of  spindle-  or  oat-shape,  called  epithelioid  cells,  which  are  akin 
to  the  fibroblasts  of  ordinary  granulation  tissues,  since  they  can  form  fibrous 
tissue  if  the  victory  lies  with  the  tissues.  Where  the  bacilli  are  getting  the 
upper  hand  the  central  parts  of  the  tubercle  undergoes  necrosis  and  becomes 
converted  into  cheesy  material  (hence  the  process  is  called  caseation), 
appearing  on  microscopical  examination  as  formless  debris.  Where  the 
process  of  degeneration  is  progressing  but  slowly,  giant  cells  are  found  in  the 
central  parts  of  each  tubercle.  These  are  notable  for  their  size,  which  is 
many  times  greater  than  the  largest  of  the  other  cells,  and  for  possessing 
many  nuclei  which  are  arranged  along  one  border  of  the  cell  in  a  radial 
manner.  These  giant  cells  are  apparently  the  result  of  an  ineffectual  at- 
tempt on  the  part  of  the  epithelioid  cells  to  undergo  division,  which  at  last 
overcome  by  the  toxins  of  the  bacilli  are  only  able  to  grow  larger  and  cause 
their  nuclei  to  divide.     That  giant  cells  in  tubercles  are  degeneration- 


'.';»'         flu.    v         •'*/    .'.•'.'  ••:•'•••■ 


18$  A  TEXTBOOK  OF  SURGERY 

products  is  suggested  by  the  fact  that  often  a  large  part  of  the  body  of  such 
rolls  is  ill-stained  and  clearly  undergoing  the  changes  of  caseation.  Giant 
cells  arc  found  specially  where  the  condition  is  slowly  progressing,  being  less 
numerous  in  very  rapidly  advancing  tuberculous  foci.  A  fully-formed 
tubercle  then  consists  of  a  central  mass  of  epithelioid  cells  and  a  few  bacilli, 
with  or  without  giant  cells  ;  around  this  central  part  is  a  zone  of  small  round 
cells  consisting  of  little  hut  a  nucleus,  the  whole  surrounded  by  a  zone  of 
dighl  hypeiaeniia.  Such  a  tubercle  is  about  the  size  of  a  pin's  head  or 
millet  seed  (hence  the  name  miliary  tubercle).  In  texture  it  is  as  hard  as 
cartilage  and  is  known  as  the  grey  or  miliary  tubercle,  which  may  be  seen  in 

a  characteristic  manner 
covering  the  peritoneum 
in  great  numbers  in 
cases  of  the  ascitic  form 
of  tuberculous  perito- 
nitis. 

Further  Changes 
in  Tubercles.  (1)  The 
process  may  soon  end 
in  healing,  the  epithe- 
lioid cells  forming  fibrous 
tissue  and  the  bacilli 
being  destroyed. 

(2)  The    process     of 
'.i.    Tubercles  in  the  wall  of  '-cold"  abscess         destruction  in  the  centre 
(magnified).  of  the  tubercle  may  pro- 

gress, the  cells  there  de- 
generating  into  a  dry,  soft,  friable,  "  cheesy  "  material.  This  is  known  as 
cast  "'"  /'  and  is  typical  of  advancing  tuberculous  lesions. 

The  grey  miliary  tubercles  become  yellow  as  they  caseate  in  the  centre, 
gradually  growing  in  size.  Several  neighbouring  tubercles  may  in  this 
manner  coalesce,  fanning  a  caseous  node  containing  in  its  periphery  scattered 
giant  cells  surrounded  by  epithelioid  cells  and  outside  these  a  small  round- 
celled  infiltration.  Caseation  is  the  result  in  a  large  number  of  cases  of 
tuberculous  infection.  As  mentioned,  the  material  is  usually  dry,  soft  and 
friable,  and  may  remain  in  this  condition  for  long  periods,  but  very  often 
becomes  liquefied  and  breaks  down  further  into  pus,  or  in  other  words  the 
mass  of  caseating  material  becomes  a  cold  abscess.  In  other  instances  the 
necrotic  tissue  is  tough  and  solid,  not  at  all  unlike  the  central  slough  of  a 
syphilitic  gumma  and  may  well  be  called  a  "  tuberculous  gumma." 

Healing  may  occur  at  any  stage  of  this  caseating  process,  the  necrotic 
material  being  absorbed  and  replaced  by  fibrous  tissue,  often  with  deposit  of 
lime-salts  or  calcification,  which  is  very  common  in  healed,  obsolete  tuber- 
culous foci,  where  caseation  and  the  formation  of  a  cold  abscess  have  taken 
place. 

In  other  cases  the  cold  abscess  thus  formed  may  spread  widely,  burrowing 


SPREAD  OF  TUBERCULOSIS  189 

along  the  paths  of  least  resistance,  spreading  along  inside  dense  aponeurotic 
planes,  destroying  the  muscles  and  other  soft  tissues  inside,  till  it  reaches  the 
surface,  where  it  may  burst  forming  a  long  sinus.  Psoas  abscess  arising  in 
tuberculous  caries  of  the  lumbar  vertebrae  is  a  good  example  of  such  a  cold 
or  '•  gravitation  "  abscess. 

Besides  this  local  spread,  which  is  of  the  nature  of  ulceration,  tuberculosis 
may  spread  and  become  generalized  as  follows. 

(1)  By  dissemination  along  lymph  channels.  This  is  the  usual  manner  of 
spread  from  one  group  of  glands  to  another,  and  also  when  a  group  of  glands 
is  infected  from  some  primary  focus,  in  the  skin,  intestine,  lung,  &c,  but 
this  method  of  spread  is  really  very  slow  and  general  dissemination  can 
hardly  be  said  to  arise  in  this  manner. 

(2)  At  anytime  tubercle  bacilli  may  obtain  entrance  to  the  blood-stream, 
and  thus  be  carried  to  a  distant  part  of  the  body,  giving  rise  to  a  haeniato- 
genous  infection.  Tuberculosis  of  the  testis,  kidney,  bones  and  joints  is  of 
this  nature,  being  secondary  to  some  original  focus  in  the  bronchial  or 
intestinal  glands  or  elsewhere.  In  many  instances  such  dissemination  is 
localized  to  some  part  or  organ  which  has  not  infrequently  been  previously 
damaged  by  injury  or  another  infection.  In  other  instances  such  hseniato- 
genous  infection  may  be  widespread  and  generalized ;  that  is  to  say  a 
tuberculous  septicaemia  or  pyaemia  may  arise.  This  general  spread  is 
known  as  general  miliary  tuberculosis  from  the  formation  of  the  typical, 
grey,  miliary  tubercles  all  over  the  body,  especially  in  the  lungs,  peritoneum, 
meninges,  kidneys,  &c.  ;  such  a  general  outburst  of  tuberculosis  invariably 
proves  fatal. 

(3)  Less  commonly  tubercle  bacilli  are  carried  along  the  paths  of  secre- 
tions, e.g.  the  larynx  may  be  infected  from  the  lung  by  the  passage  of  infected 
sputum.  In  some  instances,  perhaps,  the  bladder  is  infected  by  the  passage 
of  urine  containing  tubercle  bacilli  from  the  kidney,  though  it  is  fairly 
certain  that  in  most  instances  the  spread  in  this  region  is  along  the 
lymphatics. 

Diagnosis.  The  methods  appropriate  differ  in  tuberculosis  of  different 
parts,  thus  : 

(1)  The  organism  may  be  discovered  (recognized  by  its  staining  reactions) 
in  the  discharge  from  the  site  of  lesion  ;  in  the  sputum,  urine,  the  pus  from  an 
abscess,  &c. 

(2)  By  inoculation  of  guinea-pigs.  This  is  useful  where  the  bacilli  are 
scanty  or  perhaps  in  some  form  unrecognizable  by  ordinary  microscopic 
methods ;  if  inoculated  into  the  peritoneum  of  guinea-pigs,  manifestations 
caused  by  the  bacilli  will  appear  in  a  few  weeks. 

(3)  By  examination  of  portions  of  the  local  disease  removed  for  this 
purpose.  This  is  a  useful  plan  to  diagnose  enlargement  of  glands  andother 
tumour  formations.  The  characteristic  appearance  of  the  grey  tubercles 
under  the  microscope  is  sufficient  even  if  the  bacilli  cannot  be  detected. 
Finding  acid-fast  bacilli  only  confirms  the  diagnosis. 

(4)  By  means  of  tuberculin  reactions  on  infected  patients,  who  are  far 


190  \  TEXTBOOK  OF  SURGERY 

more  susceptible,  and  Bhow  more  signs  of  local  irritation  after  such  inocula- 
tions than  do  those  who  are  free  from  tuberculosis. 

Von  Pirquet's  is  the  safest  method.  In  this  an  extract  of  dead  tubercle 
bacilli  (tuberculin)  is  inoculated  into  some  scratches  on  the  skin.  If  the 
patienl  isaffected  with  tuberculosis  there  will  appear  at  the  site  of  inoculation 
within  three  days  a  well-marked  area  of  redness  and  oedema,  while  normal 
patients  Bhow  hardly  any  reaction,  it  must  be  remembered  that  tubercu- 
losis, in  Borne  minor  degree,  is  a  very  common  affection  and  the  reaction, 
it  positive,  may  be  due  no1  to  the  obvious  lesion,  but  to  some  obscure  and 
practically  obsolete  focus  in  the  depths  of  the  body.  Hence  the  positive 
reaction  is  not  very  convincing;  the  negative  reaction  or  failure  of  reaction  to 
appear  is,  however,  fairly  good  evidence  that  the  patient  is  not  suffering  wit  h 
tuberculous  infection.  Calmette's  reaction  is  similar,  but  the  tuberculin 
was  inserted  into  the  conjunctival  sac.  <  >wing  to  occasional  disasters  to  the 
eye  from  this  method  it  is  no  longer  permissible. 

Treatment.  In  all  cases  of  tuberculosis  general  treatment  should  be 
regarded  as  most  important,  and  local  treatment  considered  as  sub- 
sidiary  even  when  this  consists  of  operative  measures  of  such  magnitude 
as  nephrectomy  :  the  reason  being  that  the  focus  coming  under  the  surgeon's 
notice  is  almost  always  secondary  to  some  obscure  primary  lesion  elsewhere, 
and  even  if  such  a  secondary  focus  be  entirely  eradicated  there  will  remain 
some  chance  of  rein  fret  ion  elsewhere  from  the  original  source. 

The  general  treatment  of  tuberculosis  belongs  rather  to  internal  medicine 
than  to  surgery,  but  may  be  briefly  outlined  as  follows. 

The  patient  should  be  as  much  in  the  fresh  air  and  sunshine  as  possible. 
(  Innate  is  important ;  the  health  resorts  of  the  East  Coast  have  a  well-merited 
reputation  in  this  country  for  surgical  forms  of  tuberculosis  such  as  affections 
of  bones,  joints  and  glands.  Care  is  needed  that  under  this  regime  the  patient 
do  not  suffer  with  cold  or  be  overcome  with  heat. 

The  food  should  be  plain  but  nutritious  and  easily  digested,  care  being 
taken  not  to  overload  the  stomach  or  produce  either  constipation  or  diarrhoea. 
Fatty  food  is  essential  in  whatever  form  it  can  be  most  readily  assimilated, 
including  such  things  as  milk,  eggs,  bacon,  cod-liver  oil.  Exercise  in 
moderation  and  under  supervision  is  beneficial  in  most  cases,  but  only  where 
it  can  be  indulged  in  without  throwing  strain  on  the  affected  part.  Thus, 
in  case  of  spinal  caries,  the  completely  recumbent  position  is  at  first  advisable. 
Much  tact  and  judgmentare  deeded  to  settle  the  relative  amounts  of  rest  and 
exercise  requisite  to  attain  the  best  results.  Of  drugs,  iron  and  arsenic  are 
good,  but  these  should  be  given  in  the  more  digestible  forms,  since  on  no 
account  should  the  stomach  be  upset.  Finally  all  likely  portals  of  ingress 
for  the  tubercle  bacillus  should  be  removed  or  cured  :  enlarged  tonsils  and 
adenoid  vegetations  should  be  removed,  teeth  kepi  in  order,  sore  and 
pediculous  heads  restored  to  a  normal  condition.  &c,  for  glandular 
tuberculosis  in  many  ii  originates  through  such  portals.    Allusion  has 

already  made  to  prophylaxis  in  the  matter  of  milk  and  other  foods. 

Local  Treatment.    This  will  depend  very  much  on  the  position  of  the  lesion 


TREATMENT   OF  TUBERCULOSIS  191 

and  its  probable  course.  "Where  a  tuberculous  lesion  is  situated  in  a  part 
where  healing  is  probable  and  adequate  removal  difficult  and  likely  to  lead 
to  much  deformity,  conservative  measures  are  indicated,  but  these  should  not 
be  persisted  in  to  the  detriment  of  the  patient's  general  well-being.  Joints 
are  as  a  rule  eminently  suitable  for  conservative  measures. 

Where  the  lesion  is  in  an  organ  where  the  progress  is  inevitably  to 
destruction,  as  in  the  case  of  the  kidney,  early  operative  treatment  and 
removal  seem  the  most  reliable  method  of  procedure. 

Where  a  tuberculous  lesion  is  fairly  well  circumscribed,  and  although 
likely  to  heal  in  time  will  probably  cause  much  suppuration,  sinus  formation 
and  deformity,  and  will  take  long  in  the  process,  as  for  instance  in  the  case  of 
tuberculous  glands  of  the  neck  which  are  already  breaking  down,  operative 
treatment  is  indicated  to  remove  the  focus. 

(1)  Apart  from  operative  measures,  local  treatment  consists  in  keeping 
the  diseased  part  at  rest,  usually  by  splinting  or  encasing  it  in  plaster. 
Absolute  rest  is  of  less  importance  than  the  avoidance  of  sudden  jars  and 
strains  in  the  affected  part,  and  also  the  effects  of  pressure,  all  of  which  are 
especially  liable  to  occur  in  the  lower  limb  from  walking;  hence  the 
advisability  of  such  instruments  as  the  Thomas's  splint,  whereby  the 
weight  is  taken  entirely  off  the  damaged  limb. 

Other  non-operative  forms  of  local  treatment  are  of  little  use.  These 
comprise  counter  irritation  with  iodine  or  strapping  over  Scott's  mercurial 
dressing,  Bier's  hyperemia,  and  injecting  iodoform  into  the  affected  part. 

(2)  Local  operative  treatment.  This  is  undertaken  for  varying  conditions. 

(a)  Removal  of  a  large  focus  which  although  circumscribed  will  certainly 
destroy  the  organ  in  which  it  is  present  and  spread  elsewhere,  e.g.  the  kidney, 
testis,  tuberculous  caecum,  &c. 

(b)  Where  healing  is  greatly  expedited  by  operation,  as  in  the  case  of 
tuberculous  glands.  . 

(c)  In  diseases  of  bones  or  joints  not  reacting  to  rest  and  general  treat- 
ment. 

(d)  Where  the  lesion  has  broken  down  and  a  cold  abscess  results. 
Treatment  of  Cold  Abscess,     (i)  When  in  connection  wijth  bones 

or  joints,  especially  if  deep  seated,  it  is  worth  trying  expectant  treatment, 
i.e.  complete  rest  and  use  of  tonic  food  and  drugs.  A  good  many  cases  of 
psoas  abscess  will  become  absorbed  and  calcified  under  such  treatment. 

(ii)  Where  a  cold  abscess  is  well  localized,  as  in  a  breaking-down  lym- 
phatic gland  or  sometimes  a  subcutaneous  cold  abscess,  the  whole  may  be 
dissected  out.  This  is  excellent  treatment  where  the  tuberculous  lesion  is 
readily  accessible.  More  often  the  question  of  treatment  lies  between  aspira- 
ting or  opening  a  cold  abscess  with  the  knife. 

(iii)  Aspiration  of  a  cold  abscess  with  fine  needle  has  the  disadvantage 
that  the  thicker  parts  of  the  pus  will  not  pass  through  the  needle  ;  injection 
of  menthol  and  camphor  dissolved  in  ether  a  few  days  before  may  improve 
matters  by  rendering  the  pus  more  liquid. 

We  are  inclined  to  the  view  that  if  an  abscess  will  not  subside  on  resting 


192  A  TEXTBOOK  OF  SURGERY 

the  pari  it  will  usually  require  opening,  though  aspiration  may  always  be 
tried  as  a  preliminary  measure. 

(iv)  Opening  oi  a  cold  abscess  must  be  done  under  strict  aseptic  pre- 
cautions, the  pus  is  evacuated,  the  lining  membrane  of  granulation  tissue 
Bcraped  away  and  the  cavity  scrubbed  out  clean  with  gauze  till  dry  and 
devoid  of  pus  or  granulations  ;  any  weak  reddened  skin  over  the  abscess  (if 
nearly  pointing)  should  be  cut  away  and  the  incision  closed  carefully, 
leaving  in  a  drain  to  remove  scrum  for  twenty-four  hours.  The  injection 
of  iodoform  or  other  antisept  ics  does  not  seem  of  any  great  advantage,  if  any 
antiseptic  is  used  the  mos1  certain  is  pure  carbolic.  This  method  of  opening 
a  cold  abscess  may  be  repeated  on  several  occasions,  and  healing  is  usually 
satisfactory  if  the  aseptic  technique  is  sound. 

(v)  Simple  incision  and  letting  out  the  serous  fluid  is  good  treatment  in 
the  ascitic  form  of  tuberculous  peritonitis,  the  wound  of  course  being  care- 
fully sutured  afterwards. 

Probablv  in  this,  as  in  other  cases  where  tuberculous  foci  are  evacuated, 
the  result  depends  on  the  passage  of  serum  containing  anti-tuberculous 
Bubstancesto  take  the  place  of  the  fluid  which  has  been  removed,  and  this  has 
;i  beneficial  effect  on  the  lesion. 

Specific  treatment  of  tuberculosis  with  various  tuberculins  (i.e.  extracts 
of  dead  tubercle  bacilli)  is  still  in  a  purely  experimental  state.  Good  results 
follow  the  administration  of  tuberculin  in  some  instances,  but  it  is  impossible 
to  predict  on  clinical  or  bacteriological  grounds  which  cases  are  suitable  for 
such  measures  and  to  know  which  may  be  made  worse.  Therefore  the  ad- 
ministration of  tuberculin  should  be  confined  to  those  cases  where  the  result 
«.f  general  treatment  is  not  satisfactory  and  operative  measures  seem  contra- 
indicated,  e.g.  in  tuberculosis  of  the  bladder,  not  secondary  to  the  kidney 
or  testis,  and  sometimes  in  disease  of  bones  and  joints.  Tuberculin  must  be 
used  carefully  and  in  a  tentative  manner,  watching  the  effect  on  the  patient 
Lesi  such  inoculation  make  matters  worse.  Either  the  new  tuberculin  or 
tuberculin  R.  may  be  used,  commencing  with  a  1/20,000  mg.  in  febrile  cases 
or  1  /4000  mg.  in  chronic  conditions,  and  gradually  increasing  the  dose  up  to 
1  500  mg.*,  or  even  more.  This  treatment  should  only  be  employed  when  the 
patient  is  under  close  observation,  and  by  those  who  are  acquainted  with 
all  phases  of  the  disease. 

B.  ACTINOMYCOSIS 

The  ray  lun.L'i  or  -t  i  vpt  ot  hrix  organisms  proper,  for  it  appears  that  several 
di£feren1  species  are  responsible  for  the  lesions  known  as  actinomycosis,  occur 
in  the  form  of  a  mycelium  or  meshwork  of  fine,  long,  branching  threads 
having  a  diameter  of  aboul  •*'>;,.  bu1  of  great  length,  and  aggregated  in  small 
masses  or  colonies  the  size  of  a  pin's  head.  In  the  centre  of  such  masses  the 
thread-  are  interlaced,  being  felted  together,  while  at  the  periphery  they 

die  a  moie  radial  arrangement.  Segmentation  of  the  ihreads  is  some- 
time- noted  resembling  a  chain  of  bacilli.  In  some  parts  the  threads  are 
converted  into  rounded  bodies  arranged  in  rows  known  as  gonidia,  spores, 


ACTINOMYCOSIS  193 

cocci.  (It  is  uncertain  whether  these  are  organs  of  reproduction  or  products 
of  degeneration.)  Finally  when  growing  in  the  tissues  other  structures  called 
•■  clubs  "  are  found  ;  these  are  pear-shaped  swellings  at  the  extremities  of 
the  threads  and  arranged  radially  at  the  periphery  of  each  colony  of  mycelium, 
These  clubs  are  of  homogeneous  structure.  The  threads  and  gonidia  retain 
the  stain  by  Gram's  method,  the  clubs  lose  the  stain  by  this  method,  but 
readily  take  a  counter-stain  such  as  picric  acid.  Some  of  the  streptothrices 
are  acid-fast  and  appear  closely  allied  to  the  group  in  which  the  tubercle 
bacillus  and  its  relations  are  placed.  The  ray  fungus  is  non-motile  and 
grows  slowly  but  strongly  on  glycerine-agar  (recent  workers  maintain  that  it 
is  anaerobic). 

The  ray  fungus  causes  in  cattle  the  formation  of  chronic  granulation 
tissue  and  fibrous  masses,  often  originating  in  the  tongue  (wooden  tongue). 


Pig.  *>2.     Actinomycosis  :   a  mass  of  mycelium  in  an  abscess  (magnified). 

In  man  the  condition  is  more  suppurative  in  character,  closely  resembling 
the  lesions  due  to  the  tubercle  bacillus,  viz.  the  formation  of  granulation 
tissue  breaking  down  to  form  cold  abscesses,  in  the  pus  of  which  colonies 
of  the  organism  are  found,  visible  to  the  naked  eye  as  granules  of  whitish  or 
yellow  colour,  about  the  size  of  a  pin's  head.  Infection  with  this  organism 
seems  to  be  introduced  by  eating  cereals,  especially  barley,  and  the  lesions  are 
most  usual  in  the  mouth,  jaws  and  neck,  but  the  intestinal  tract  and  lungs 
are  also  affected.  From  these  points  of  entry  the  organism  may  spread 
locally  or  obtain  entrance  to  the  blood-stream  leading  to  pyaemia. 

Clinical  Appearances.  When  originating  in  more  superficial  parts,  as 
at  the  angle  of  the  jaw  or  the  side  of  the  neck,  the  lesion  appears  as  a  painless, 
brawny  swelling,  slowly  increasing  in  size,  which  later  becomes  red-purple 
and  boggy  and  finally  breaks  down,  bursting  through  the  skin,  discharging 
from  several  apertures  pus,  which  contains  the  colonies  of  the  organism. 
The  infection  may  also  take"  place  in  the  appendix,  or  other  part  of  the  in- 
testinal tract,  causing  symptoms  of  intestinal  derangement  and  later,  the 
local  formation  of  a  tumour,  which  if  not  removed  will  finally  burst  through 


194  \  TKXTBOOK  OF  SURGERY 

the  skin,  leading  to  the  formation  of  a  fistula.   En  the  lung  the  infection  closely 
seating  phthisis. 

/,  |  s  ».  i„  the  early  stag  a  this  has  to  be  made  from  syphilitic 
gumma  by  the  history  of  Byphilis  or  the  Wassermann  reaction,  or  from 
ma  by  exploration:  in  the  later  stages  when  fistulse  are  present 
examination  of  the  discharge  and  finding  the  fungus  should  distinguish  from 
tuberculous  or  pyogenic  lesions  and  breaking-down  malignant  growths, 
which  are  the  conditions  mosl  likely  to  be  confused  with  actinomycosis. 

•„.,  nt.  The  local  lesion  should  be  removed  as  thoroughly  as  possible 
by  excision,  or  scraping  and  paint  ing  with  pure  carbolic  acid,  according  to  its 
position  and  relations;  while  at  the  same  time  large  doses  of  iodide,  should 

be  given.  The  prognosis  is  bad  in  vis- 
ceral infections,  but  fairly  good  in  more 
superficial  lesions  treated  on  the  above 
lines. 


C.    MADURA   DISEASE   (MYCETOMA) 

This  disease  is  due  to  an  organism  of 
the  streptothrix  group  closely  allied  to 
the  actinomyces,  and  occurs  in  India, 
Algeria,    and    other    tropical    stations. 
The  lesions  are  similar  to  those  of  the 
last  described   organism,    but   of   con- 
siderably  more  chronic  nature,   taking 
years  to  make  much  headway.    There  is 
a  similar  formation  of  granulation  tissue 
resulting  in  the  formation  of  sinuses  often  involving  bones  and  joints.     The 
disease  affects  mostly  the  foot  and  leg,  but  also  the  hand.   The  colonies  of  the 
fungus  which  pass  from  the  sinuses  in  the  pus  are  likened  to  the  roe  of  fishes, 
and  occur  in  two  varieties,  the  (a)  black  and  the  (b)  pale  pink  or  yellow7. 
Clinically  the  affection  is  not  unlike  chronic  tuberculosis  of  bones  and 
joints  with  sinus  formation,  but  the  finding  of  the  roe-like  points  of  fungus  in 
the  discharge  will  settle  the  diagnosis.  As  has  been  mentioned  the  progress  is 
eminently  chronic,  lasting  many  years,  but  always  of  a  progressive  character. 
T n  nt  mi  nt.    In  contradistinction  to  their  effect  on  actinomycotic  lesions, 
iodides  appear  to  be  useless  in  this  disease,  so  that  there  only  remains  thorough 
-ion  or  curetting  followed  by  application  of  pure  carbolic  or  amputation 
if  the  part  is  badly  involved. 

D. LEPROSY 

This  disease  is  due  to  an  acid-fast  bacillus  resembling  that  of  tuberculosis 
in  practically  all  morphological  characters,  but  differing  in  the  fact  that  it 
is  difficult  to  grow  on  any  media  ;  in  fact,  it  seems  questionable  whether  the 
leprosy  bacillus  has  ever  been  cultivated. 

Leprosy  is  almost  unknown  in  this  country,  but  it  is  common  in  Norway, 
Iceland.  Russia  and  the  East.     Infection  with  the  leprosy  bacillus  leads  to 


Fio 


63.     Lepra    bacilli   in  large 
cells  (magnifii 


lepra 


LEPROSY 


195 


the  formation  of  chronic  granulation  tissue,  the  main  cells  of  which  (corre- 
sponding to  the  epithelioid  cells  found  in  tubercles)  are  very  much  larger, 
vacuolated,  and  contain  the  bacilli  in  enormous. numbers,  so  that  a  section 
of  leprous  tissue  if  stained  with  carbol  fuchsin  and  decolorized  with  acid  is 
quite  red  from  the  numbers  of  bacilli  present.  The  vast  numbers  of  the 
bacilli  present  and  the  chronicity  of  the  disease  point  to  the  absence  of  toxins 
of  any  virulence.  Two  main  forms  of  the  disease  are  described  :  (a)  the 
tuberous,  (b)  the  anaesthetic.     In  the  former  condition  there  is  a  production  of 


Fig.  G4.     Leprosy. 
(Kindly  lent  by  Dr.  Gilbert  Scott) 

granulation  tissue  chiefly  in  the  skin  and  mucous  surfaces  ;  in  the  latter  the 
lesions  are  chiefly  in  the  peripheral  nerves. 

(a)  In  the  tuberous  form  hyperaemic  patches  appear  on  the  forehead,  fore- 
arms, face,  hands  and  feet.  These  patches  very  slowly  develop  into  nodular 
masses  of  reddish-brown  colour,  which  assume  a  considerable  size  and  cause 
great  distortion  of  the  face,  thickening  of  the  nose,  lips,  supraorbital  tissues 
resulting  in  the  facial  appearance  known  as  the  "  facies  leonina." 

Caseation  of  the  granulation  masses  never  occurs  but  a  progressive  ulcera- 
tion of  extremely  chronic  character,  resulting  in  time  in  considerable  destruc- 
tion of  the  parts  affected.  The  disease  spreads  from  the  more  superficial  parts 
to  the  mucous  membranes  of  the  mouth,  pharynx,  larynx,  lungs,  and  the 
results  of  such  ulceration  combined  with  sepsis  carry  off  the  patient  after 


196  A  TEXTBOOK  OF  SURGERY 

a  of  chronic  disease.    The  sexual  organs  are  prone  to  affection,  rendering 
patients  Bterile  in  most  cases. 

■  In  the  anaesthetic  Eqrm  there  are  pains  in  the  peripheral  nerves  at  the 
commencemenl  toll. .wed  by  thickening  of  the  nerves,  from  the  formation  of 
granulation  tissue,  Leading  to  anaesthesia   paralysis  and  trophic  changes. 

a  of  skin  become  anaesthetic,  yellowish-white  in  colour,  and  slough 
Blowly  away.  Owing  to  the  anaesthesia,  minor  injuries  arc  not  noted  and 
painless  whitlows  readily  form  leading  to  destruction  of  portions  of  fingers 
and  toes,  and  in  this  way.  as  time  goes  on.  considerable  maiming  takes  place, 
the  extremities  being  gradually  destroyed. 

Qp  to  the  present  no  treatment  has  been  found  very  satisfactory  ;  chaul- 
moogra  oil.  both  externally  and  internally,  and  local  application  of  X-rays 
cause  temporary  improvement.  The  use  of  an  extract  of  leprous  bacilli  is 
also  well  reported.  Segregation  of  infected  persons  is  at  present  the  only 
means  of  efficiently  dealing  with  the  disease. 

5.  DISEASES   CAUSED   BY  INFECTION   WITH   PROTOZOA 

The  importance  of  protozoa  as  cause  of  disease  has  been  gradually 
recognized  during  the  last  twenty  or  thirty  years,  till  now  it  must  be  admitted 
that  imt  eyen  bacteria  can  be  regarded  as  of  greater  importance  in  this 
respect.  Most  of  the  protozoal  infections,  however,  belong  rather  to  the 
province  of  internal  medicine  than  of  surgery,  and  especially  of  such  diseases 
occurring  in  the  East  and  the  Tropics.  As,  however,  several  of  these  diseases 
lead  to  surgical  complications,  a  brief  survey  of  protozoal  infections  should 
be  of  interest  to  the  student.  One  group  at  any  rate,  the  spirilla,  which  we 
now  regard  as  protozoa,  i.s  of  the  greatest  interest  alike  to  physicians, 
surgeons,  bacteriologists,  and  those  whose  work  is  connected  with  public 
health  and  morals  ;  since  in  this  group  we  find  the  famous  treponema  palli- 
dum or  spirochete  of  syphilis. 

The  protozoa  concerned  in  causing  infective  diseases  are  amoebae, 
sporozoa,  flagellata  and  spirilla. 

('/)  Ankkb.e  (Dysentery).  Several  varieties  of  this  organism  have  been  dis- 
covered in  tropical  dysentery.  The  pathogenic  varieties  differ  from  the 
amoeba  normally  inhabiting  the  colon  in  possessing  a  clear  ectosarc,  well 
denned  from  the  granular  endosarc  ;  while  the  harmless  organism  is  granular 
throughout.  The  pathogenic  amoeba?  have  been  found  in  pure  culture  in 
abscesses  of  liver  and  brain  secondary  to  dysentery. 

(6)  Sporozoa  (Malaria).  These  organisms  possess  a  complex  life  history, 
passing  through  a  sexual  stage,  in  which  conjugation  takes  place,  and  an 
asexual  foim  where  the  organism  breaks  up  into  numerous  spores.  Several 
pathogenic  varieties  are  known,  and  are  the  causal  agents  of  various  types 
of  malaria.  This  disease  comes  into  surgical  cognisance  as  a  cause  of  enlarge- 
ment o!  tin-  spleen,  which  is  generally  regarded  as  of  diagnostic  importance 
only,  and  outside  surgical  interference.  Cases  are,  however,  reported  of 
operative  treatmenl  for  rupture  of  malarial  spleen,  with  successful  issue. 

(c)  Flaoellata  and  Allied  Organisms  (Delhi  Boil).  The  trypanosomes 


SYPHILIS  197 

responsible  for  the  tsetse -fly  disease  of  cattle  and  sleeping  sickness  of  man 
do  not  call  for  surgical  consideration,  but  closely  allied  organisms,  the 
Leishman-Donovan  bodies,  appear  to  be  the  causal  agent  not  only  in  tropical 
splenomegaly  or  kali-azar,  but  also  are  able  to  produce  the  local  lesion  known 
as  Delhi  or  Aleppo  boil.  In  this  disease  there  are  found  ovoid  bodies  of  the 
above-mentioned  type,  2/x  to  i/u  in  diameter.  The  sore  develops  as  a  red 
papule  which  breaks  down  into  an  ulcer,  usually  situated  on  the  face  or 
forehead  and  often  lasting  some  months.  The  ulcer  may  heal  spontaneously, 
but  the  process  of  healing  is  accelerated  by  scraping  and  painting  with  pure 
carbolic  acid. 

(d)    THE  SPIRILLOSES  OR  INFECTIONS  WITH   SPIROCHETES 

OR  SPIRILLA 

These  organisms  were  formerly  classed  with  bacteria,  but  it  is  now 
considered  that  they  are  really  protozoa.  Spirilla  may  infect  the  blood 
alone  as  is  the  case  in  relapsing  and 
African  tick-fever,  or  may  affect  both 
blood  and  tissues  as  in  syphilis  and  yaws. 

Syphilis  (Lues,  Pox).  Since  the 
discovery  of  the  spirochseta  pallida  or 
as  it  is  sometimes  called  the  treponema 
pallidum,  by  Schaudinn  and  Hoffmann 
in  1905,  a  vast  amount  of  work  has 
been  done  in  verifying  this  important 
piece  of  research. 

The    organism   has    b3en    found   in 
practically    all    tissues    including    the 
blood,  and  in  all  stages  of  the  disease 
whether  congenital  or  acquired,  including   Fig.  65.    Spirocheeta  pallida  (magnified), 
the    diseases     previously    described    as 

"  parasyphilitis"  e.g.  tabes  (Noguchi),  and  since  this  observer  has  succeeded 
in  growing  the  organism  under  strictly  anaerobic  conditions,  and  successfully 
inoculating  monkeys  with  such  cultures,  producing  typical  syphilitic  papules 
and  causing  the  Wassermann  reaction  to  appear  in  their  blood,  it  must  be 
admitted  that  the  spirochgete  is  the  causal  agent  of  syphilis. 

The  disease  is  of  recent  origin  in  Europe,  having  been  introduced  from 
the  New  World,  possibly  by  the  crew  of  Columbus,  when  it  rapidly  passed 
through  surrounding  countries,  spreading  havoc  in  its  course. 

Pathology.  The  treponema  pallidum  is  a  motile,  spiral  thread,  4  to  lifx 
in  length  but  of  extreme  tenuity,  being  only  -2ofx  in  diameter,  and  as  it  is  but 
feebly  retractile  is  not  easy  to  see.  The  turns  of  the  spiral  number  about 
fourteen,  and  there  is  a  single  flagellum  at  either  end.  The  organism  can 
be  demonstrated  by  various  staining  methods,  such  as  Giemsas  (Azur-Eosin 
method)  in  scrapings  from  chancres,  or  that  of  Levaditi  (silver  nitrate 
impregnation  method)  in  sections. 

Inoculations    with    spirochetes    have    proved    successful    in    animals  ; 


A  TEXTBOOK  OF  SURGERY 

in  chimpanzees  both  primary  and  secondary  lesions  appear,  and  the  changes 
in  the  serum,  giving  the  Wassermann  reaction,  develop.  In  rabbits  local 
lesions  can  be  produced,  e.g.  Byphilitic  orchitis  by  inoculating  the  testes; 
and  in  young  rabbits  generalized  syphilis  has  been  produced.  Hitherto 
nothing  of  value  has  been  done  with  Berum  therapy.  Syphilis  is  always  due 
to  infection  with  the  spirochete  cither  before  or  after  birth.  In  the  latter 
instance  the  infection  is  into  some  slighl  lesion  ol  the  skin  or  mucosa,  usually 
on  the  genitalia.  In  the  former  instance.  i.e.  before  birth,  infection  passes 
from  the  mother  to  the  foetus  through  the  placenta.  Syphilis  arising  in  this 
manner  is  called  congenital,  a  better  term  than  hereditary,  which  is  some- 
times emplo\  ed  since  there  is  no  real  comparison  between  congenital  syphilis 
and  hereditary  disease  such  as  hemophilia.  In  fact,  congenital  syphilis 
differs  only  from  acquired  variety  (arising  by  infection  after  birth),  in  that 
it  is  acquired  in  utero,  and  the  spirochete  acting  on  much  more  embryonic 
es,  proiluc.  changes  of  a  rather  different  character  from  those  produced 
in  more  fully  forme  1  tissues.  For  clinical  purposes  the  distinction  of  ac- 
quired syphilis  due  to  infection  after  birth,  and  congenital  syphilis  due  to 
infection  in  utero,  is  useful. 

Acquired  Syphilis.  From  its  clinical  aspects,  syphilis  is  usually 
divided  into  three  stages,  primary,  secondary,  and  tertiary,  which  are 
convenient  phrases  and  are  associated  with  different  types  of  lesion,  but  at 
the  same  time  it  must  be  stated  that  there  is  no  sharp  line  of  distinction 
between  these  stages;  the  lesions  of  primary  and  early  secondary  syphilis 
habitually  coexist,  while  secondary  and  tertiary  affections  are  not  infre- 
quently present  together. 

From  the  standpoint  of  infection  we  may  regard  the  stages  as  follows  : 
In  th<-  primary  stage  the  spirochetes  are  effecting  the  local  lesion,  which. 
as  their  action  is  slow,  takes  some  weeks  to  develop  ;  at  the  same  time  they 
are  diffusing  into  the  blood  and  becoming  generalized,  and  by  the  time  the 
local  reaction  is  really  well  developed,  there  is  in  addition  a  general  infection 
shown  by  the  serum  reaction.  The  clinical  signs  of  this  generalization  of  the 
disease  take  some  weeks  to  develop,  in  the  form  of  eruptions  on  the  skin 
and  mucous  surfaces,  fever,  joint-affections,  &c. 

During  the  stage  of  general  infection  the  spirochetes  are  disseminated 
through  the  body  and  the  patienl  is  highly  infectious.  The  secondary  or 
generalized  stage  inns  its  course  and  the  patient  passes  into  the  tertiary  or 
latent  si  igein  which  the  spirochetes  are  localized  in  some  part  of  the  body  and 
are  comparatively  inert,  only  occasionally  breaking  out  and  giving  rise  to  the 
formation  of  gummata  and  other nbro-granulomatous  formations,  or  to  affec- 
tions of  the  central  nervous  system  such  as  tabes  and  general  paralysis. 

In  the  tertiary  stage  the  patient  is  very  slightly  infectious  and  may  beget 
normal  children.  We  may  then  compare  syphilis  with  other  generalized 
infections  Buch  as  enteric3  but  the  former  is  far  more  chronic  and  prolonged. 
'Ih"  secondary  stage  of  syphilis  corresponds  with  the  active  stage  of  enteric, 
with  general  manifestations,  fever.  &c.  The  tertiary  stage  of  syphilis  may  be 
compared  with  the  residual  lesions,  occurring  after  enteric,  such  as  caries  of 


PRIMARY  SYPHILIS  199 

bones,  e.g.  typhoid  spine  or  hip  or  the  formation  of  gall-stones  from  mild 
catarrh  of  the  bile  passages,  which  may  be  contrasted  with  gummatous 
formations.  The  parallel  will  be  further  convincing  when  we  recall  the 
condition  of  typhoid  carriers  who  retain  the  power  of  infection  with  enteric 
germs  for  an  indefinite  number  of  years  :  still  there  is  this  great  contrast 
between  the  two  diseases  ;  whereas  in  the  tertiary  or  para  syphilitic  stages  of 
syphilis  the  patient  is  practically  non-infectious  but  is  yet  liable  to  develop 
lesions,  on  the  other  hand,  typhoid  carriers  preserve  their  own  health 
but  are  a  source  of  danger  to  others,  showing  the  difference  the  body  pre- 
sents with  regard  to  developing  immunity  to  the  two  diseases. 

Primary  Syphilis.  Infection  is  due  to  the  introduction  of  the  spiro- 
chete through  some  breach  in  the  epidermis  which  may  be  microscopic,  and 
is  usually  on  the  genitals,  involving  the  prepuce,  glans,  body  and  frsenum  of 
the  penis  in  men,  and  the  labia  minora,  fourchette,  &c,  in  females.  Less 
often  does  infection  take  place  in  other  parts  of  the  body  as  the  lips  or  eyelids 
from  kissing  by  lips  affected  with  mucous  patches,  or  the  finger  of  medical 
men  from  examining  syphilitic  women,  the  tonsils  and  pharynx  from  the 
use  of  infected  instruments,  or  other  parts  of  the  body  by  tattooing,  where 
the  operator  uses  infected  saliva  to  moisten  his  pigments.  After  infection 
there  is  a  latent  period  of  two  to  six  weeks,  before  the  local  or  primary  lesion 
begins  to  appear. 

The  initial  lesion  of  syphilis,  known  as  a  "  hard  sore,"  "  Hunterian 
chancre,"  "  primary  lesion,"  &c,  consists  of  a  slightly  ulcerated  surface, 
below  which  the  skin  or  mucosa  is  densely  infiltrated  with  small  round  cells 
and  fibroblasts,  and  young  recently-formed  connective  tissue. 

Clinically  the  hard  chancre  is  a  raw  area,  slightly  raised,  red  and  glazed 
on  the  surface  with  but  little  discharge,  which  is  hard  and  resembles  to  the 
touch  a  piece  of  cartilage  let  into  the  skin,  and  has  also  been  compared 
to  a  button  felt  through  a  thickness  of  linen.  The  size  varies  but  is  usually 
a  diameter  varying  between  that  of  a  one-  and  a  two-shilling  piece. 

In  addition  to  the  local  hard  sore,  there  develops,  slightly  later,  enlarge- 
ment of  the  glands  into  which  drain  the  lymphatics  of  the  affected  part  ;  of 
the  groin  if  the  chancre  is  on  the  penis,  in  the  submaxillary  glands,  from  labial 
chancre,  &c.  These  glands  are  painless,  discrete,  hard,  enlarged  from  four 
to  six  times  their  normal  size,  and  since  they  remain  quiescent  for  consider- 
able periods,  neither  subsiding  nor  suppurating,  they  are  aptly  described  as 
"  indolent  buboes.  "  Induration  of  the  lymphatic  channels  running  between 
the  sore  and  the  bubo  can  often  be  made  out ;  especially,  if  the  chancre  is 
penile,  can  the  dorsal  lymphatics  be  felt  as  dense  cords  through  the  fine  skin 
on  the  dorsum  of  the  penis.  A  chancre  uncomplicated  by  other  infection  is 
typically  indolent  and  does  not  heal  for  many  weeks  even  under  aseptic 
conditions,  unless  specific  treatment  be  adopted  ;  hence  indolent  sores  are 
always  to  be  suspected  of  being  syphilitic  in  origin,  especially  if  found  in 
such  likely  situations  as  the  fingers  of  practitioners,  and,  if  there  is  also 
indolent  enlargement  of  the  corresponding  glands,  the  probability  becomes 
very  near  a  certainty. 


A  TEXTBOOK  OF  SURGERY 

Variations  in  the  Form  of  Chancres.  Considerable  variations  are 
Doted,  both  from  the  response  of  different  patients  to  the  irritation  of  the 
virus  and  from  the  presence  of  other  infections  as  well  as  that  of  syphilis. 
The  type  described  is  fairly  common,  but  others  are  often  met  with  in 
practice,  as  follows 

(a)  The  local  reaction  of  the  1  issues  may  be  very  slight,  the  chancre  being 
a  Bimple,  raised  papule  of  dusky  hue.  without  manifest  ulceration:  the 
presence  of  such  a  papule  with  indolently  enlarged  inguinal  glands  render  a 
diagnosis  of  syphilis  probable,  and  further  investigation  of  the  serum,  orfor 
the  advent  of  secondaries,  is  essential  before  deciding  that  some  less  import- 
ant condition  is  present. 

(6)  Chancres  concealed  under  a  tight  prepuce  are  suspected  when  a 
purulent  discharge  is  noted  from  the  preputial  meatus,  and  the  indurated 
patch  can  often  be  felt  through  the  foreskin.  Such  concealed  chancres  on 
the  inner  surface  of  the  prepuce  or  the  glans  may  be  of  rounded  shape,  but  if 
about  the  Eraenum  are  often  ill-defined  and  simply  irregular  areas  of  induration. 
The  presence  of  indolent  enlarged  glands  of  the  groin  will  assist  in  diagnosis, 
and  slitting  up  the  foreskin,  which  forms  part  of  the  treatment  of  all  severe 
balanitis,  will  allow  the  condition  to  be  inspected  more  closely. 

(r)  Urethral  chancres  are  uncommon  and  are  found  a  short  distance  from 
the  meatus  inside  the  urethra.  A  discharge  of  pus  from  the  urethra  and  an 
induration,  felt  through  the  glans.  will  render  further  investigation  necessary. 

(<l)  .Mixed  infections  are  common.  Thus  a  hard  chancre  may  originate 
in  the  remains  of  a  healing  soft  sore  (the  more  evanescent  infection  with 
Ducrev's  bacillus  coining  to  an  end  just  about  the  time  that  an  infection 
with  the  spirochete,  which  occurs  at  the  same  act  of  coitus,  is  beginning  to 
develop  a  local  reaction).  In  other  instances  a  pyogenic  infection  may 
complicate  a  hard  sore  and  is  likely  to  lead  to  a  severe  type  of  ulcer,  spreading 
rapidly  (phagedenic  ulceration).  The  retention  of  discharge  under  a  tight 
prepuce  is  often  an  important  adjunct  in  rendering  severe  the  progress  of 
a  concealed  chancre.  In  such  cases  the  inguinal  glands  are  often  matted 
together,  painful,  oe  Lematousand  likely  to  suppurate.  The  picture  is  unlike 
that  of  an  ordinary  chancre,  but  such  phagedenic  conditions  are  often  syphi- 
litic and  should  be  regarded  as  such  unless  the  contrary  can  be  proved. 

(' )  Chancres  are  usually  single,  but  multiple,  simultaneous  infections  result- 
ing in  multiple  chancres  (2  6)  are  by  no  means  uncommon;  besides  the  prepuce 
the  skin  of  the  penile  body  or  that  of  the  thighs  or  abdomen  may  be  affected. 

(/)  Chancres  in  women  are  often  not  found,  partly  because  the  induration 
is  less,  chiefly  because  women  only  come  for  advice  when  the  secondary  stage 
is  well  developed  and  the  primary  sore  is  receding  ;  moreover,  when  the  diag- 
oosisof  generalized  syphilis  is  obvious  from  the  cutaneous  lesions,  to  search  for 
a  chancre  is  waste  of  time  and  may  lead  to  infection  of  the  examining  finger. 

(ry)  Extragenital  chancres  occur  in  various  places,  such  as  the  lips,  fingers, 
eyelids,  nipples,  and  are  likely  to  escape  diagnosis  for  some  while.  Such 
chancres  are,  as  a  rule,  larger  and  more  definitely  ulcerated  than  are  penile 
chancres,  and  also  less  indurated,  but  with  more  surrounding  oedema.     The 


CHANCRES 


201 


appropriate  lymph  nodes  show  indolent  enlargement,  and  later,  secondary 
lesions  appear.  It  is  well  to  suspect  ulcers  whose  origin  is  not  very  obvious 
of  being  chancres  until  the  contrary  can  be  proved. 

As  previously  mentioned,  the  course  of  chancres  is  protracted  and  they 
may  persist  for  weeks  or  months  unaltered,  unless  specific  treatment  be 
employed.  Where  a  mixed  infection  is  present  the  ulceration  may  progress 
rapidly,  much  penile  tissue  being  destroyed,  while  if  the  chancre  be  of  the 
papular  type  it  is  likely  to  escape  notice.  Scarring  from  chancres  is  unusual, 
unless  there  has  been  a  mixed  infection  with  pyogenic  organisms.    In  the  later 


Fig.  66.     Syphilitic  chancres  of  the  upper  and  lower  lips.     Note  also 

the  enlargement  of  the  submaxillary  and  submental  lymph  nodes. 

(Kindly  lent  by  Dr.  Gilbert  Scolt) 

stages  of  syphilis  a  gummatous  lesion  of  the  prepuce,  starting  in  the  situation 
of  a  former  chancre,  may  be  mistaken  for  chancre.  This  will  be  discussed  later. 
Diagnosis.  The  induration,  indolent  appearance  of  the  ulcer,  and  the 
painless  bubo  will  distinguish  chancres  from  soft  sores  and  herpetic  ulcers. 
But  in  the  latter  instances  the  possibility  of  a  double  infection  should  be 
borne  in  mind,  and  if  the  diagnosis  of  soft  sore  be  made  the  possibility  of 
syphilis  should  not  be  excluded  till  six  weeks  have  elapsed  without  the 
appearance  of  induration  of  the  seat  of  previous  ulceration,  or  detection  of 
spirochetes  in  the  surface  of  the  ulcer,  or  the  development  of  bullet  bubo, 
which  are  the  criteria  of  the  primary  lesion  of  syphilis.     From  epithelioma 


\  TEXTBOOK  OF  SURGERY 

(squamous-celled  cancer)  of  the  penis,  diagnosis  is  usually  easy  from  the 
history  of  venereal  possibilities,  the  rapid  growth  up  to  a  certain  point,  and 
after  that  the  indolent  stationary  condition  of  the  ulcer,  whereas  in  epithe- 
lioma the  ulceration  Bteadily  advances,  and  the  induration  is  harder  and 
more  widespread  than  is  the  case  in  chancres,  also  the  secondary  glands  of 
the  groin  may  be  unaffected  at  first  in  epithelioma,  but  later  become  larger 
and  harder.  There  is  more  difficulty  where  the  prepuce  is  tight  and  suppura- 
tion is  taking  place  under  this  with  palpable  induration.  To  ascertain  the 
puce  should  always  be  slit  up  in  such  cases  and  thorough 
investigation  made  ;  if  in  doubt  a  portion  of  the  ulcer  may  be  removed  for 
microscopic  examination.  In  the  tertiary  stage,  cutaneous  gummata  not 
infrequently  develop  in  the  situation  of  a  previous  chancre;  in  such  instances 

sharply  punched-out  ulcer,  without  induration  of  the  base  and  without 
enlargement  of  tie-  lymphatic  glands  as  well  as  the  history  of  previous 
infection,  will  render  diagnosis  fairly  easy.  But  where  the  gummatous  con- 
dition is  more  superficial  and  there  is  some  enlargement  of  the  inguinal  glands, 
remaining  from  past  inflammatory  conditions,  more  care  is  needed  to  separate 
the  conditions. 

8»  ondaby  Syphilis.  This  stage  consists  in  the  manifestation  of  signs 
ueral  infection  with  the  spirochete,  but  its  onset  does  not  commence 
till  some  little  while  after  tin'  organisms  have  spread  throughout  the  body, 
else  excision  of  a  chancre  before  secondaries  appear  would  cut  short  the 
.-.  hich  unfortunately  is  not  the  case.  In  secondary  syphilis,  as  in 
other  'j'-neralized  infections,  the  signs  are  manifold,  including  fever,  wasting, 
malaise,  eruptions  on  the  skin  and  mucous  surfaces,  and  affections  of  bones, 
joints,  and  viscera.  Fever  varies  much  in  its  degree,  in  many  cases  being 
practically  negligible,  in  other  instances  being  high  enough  to  suggest  a 
more  acute  condition  :  pyrexia  above  101°  is  uncommon,  but  weakness, 
want  of  appetite,  anaemia,  headaches  and  diffuse  bone  pains  are  usual. 
Enlargement  of  lymph-nodes  is  a  very  general  sign,  and  besides  the  local  bubo 
there  is  a  general,  indolent,  painless,  lymphadenitis  affecting  particularly 
the  glands  along  the  posterior  edge  of  the  sternomastoid  and  the  epitroclear 
glands.  Associated  with  tie-  glandular  swellings  an  excess  of  lymphocytes 
in  the  blood  may  be  noted. 

Lesions  <>f  the  Cutaneous  and  Mucous  Surfaces  or  Secondary 
SyphilideS.  In  the  skin  there  are  signs  of  inflammation  passing  through 
the  stages  described  under  Inflammation  and  its  sequelae,  viz.  hyperaemia, 
exudation,  suppuration  and  even  Bloughing  in  the  more  severe  cases. 

II  persemia  is  noted  .1-  a  diffused  mottled  redness  of  the  skin  not  unlike 
the  ra>h  of  measles.  This  "  ro-eolar  "  rash  appears  early,  usually  within  two 
mouths  of  infection,  on  the  chest  and  abdomen  ;  it  disappears  on  pressure, 
and  ew  weeks  only,  leaving  some  brownish  staining  for  awhile  after 

its  d  ince.     At  this  stage  congestion  of  the  fauces  is  noted,  showing 

•  in-  part  also. 

>i  into  the  skin  leads  to  the  formation  of  the  papular  rash,  which 
is  the  most  common  secondary  lesion,  and  consists  of  slightly  raised  reddish- 


SECONDARY  SYPHILIS  203 

brown  papules  which  appear  on  the  chest,  abdomen  and  flexor  surfaces  of 
the  limbs,  also  on  the  forehead,  where  they  form  the  "  corona  veneris." 
These  papules  are  slightly  raised,  can  be  felt  on  palpation  (the  epidermis 
is  slightly  thickened  and  later  desquamates),  do  not  fade  on  pressure,  and 
contain  a  brown  pigment  which,  together  with  the  hypersemia,  gives  the 
characteristic  colour  so  aptly  compared  to  the  lean  of  raw  ham. 

The  papular  is  more  common  than  the  roseolar  rash,  lasts  longer,  and  is 
liable  to  be  modified,  especially  if  sepsis  intervenes,  in  various  ways  becoming 
pustular,  rupial,  squamous,  or  eondylomatous. 

Pustular  syphilides  are  the  result  of  suppuration  occurring  in  the  infil- 
tration of  papules,  and  naturally  occur  at  a  later  stage  than  the  latter,  being 
most  usual  on  the  scalp  and  forehead. 

The  terms  rupia  and  ecthyma  are  applied  to  large  pustules  which  break 
and  leave  shallow  ulcers,  which  may  spread  to  a  considerable  size  and  are 
covered  with  dried  crusts  of  their  viscid  discharge.  These  crusts  collect  to 
a  considerable  thickness  and  resemble  limpet  shells  in  appearance.  These 
last  varieties  are  noted  in  the  later  stages  of  secondary  syphilis,  i.e.  after 
six  months,  and  hi  debilitated  subjects. 

Squamous  syphilides  are  the  result  of  excessive  formation  of  epithelium 
on  the  surface  of  papules,  which  does  not  readily  desquamate,  and  results 
in  the  appearance  of  areas  of  skin  covered  with  silvery  scales,  under  which 
the  hyperamiic  skin  can  be  faintly  seen.  These  lesions  have  a  considerable 
resemblance  to  those  of  psoriasis,  but  do  not  affect  the  extensor  services  nor 
such  large  areas  as  the  latter.  The  silvery  scales  are  less  regular  and  there  is 
no  subjective  irritation  in  the  syphilitic  lesion.  A  similar  thickening  of 
epidermis  on  the  soles  and  palms  in  the  later  stages  of  secondary  syphilis  is 
known  as  palmar  or  plantar  psoriasis. 

Condylomas.  Where  this  overgrowth  of  epithelium  occurs  in  moist  situa- 
tions, such  as  the  folds  of  the  nates,  around  the  scrotum,  and  labia,  or  occasion- 
ally in  the  axilla,  the  squamous  syphilide  assumes  a  different  appearance. 

The  thickened  epithelium  forms  sodden,  whitish  masses  over  the  inflamed 
hypertrophic  papillse  of  the  subjacent  dermis.  Such  a  formation  is  known 
as  a  flat  condyloma.  Similar  conditions  occurring  on  mucous  surfaces,  e.g. 
lips,  tongue,  are  known  as  "  mucous  patches."  If  these  condylomas  are 
neglected  the  irritation  leads  to  increased  overgrowth  of  the  papilla?  and 
warty  or  cauliflower  projections  appear  with  more  or  less  superficial  ulcera- 
tion and  foul  discharge  ;  these  are  described  as  "  pointed  condylomas." 

Mucous  Syphilides.  These  are  formed  on  the  same  line's  as  those  of 
the  skin.  Allusion  has  been  made  to  the  congestion  of  the  fauces  correspond- 
ing to  the  roseolar  rash.  The  formation  of  papules  on  mucous  surfaces 
always  assumes  the  character  of  "mucous  patches"  owing  to  their  moist 
situation  causing  a  softening  of  the  overgrown  epithelium.  Such  mucous 
patches  are  common  on  the  inner  side  of  the  cheek  and  lips,  on  the  tongue,  and 
about  the  fauces  and  tonsils.  In  the  latter  situation  they  are  often  described 
as  "  snail-track  "  ulcers.  The  first  part  of  the  term  is  good  as  they  closely 
resemble  the  tracks  of  snails,  being  greyish  white,  shiny,  translucent  smears 


\    IK.Y!  BOOK  OF  SURGERY 

on  the  parts  affected ;  but  they  are  nol  ulcers;  on  the  contrary,  the  appear- 
ance is  tine  to  increased  thickening  and  failure  to  desquamate  on  the  part  <>l 
the  affected  epithelium.  Similar  mucous  patches  forming  in  the  larynx  and 
pharynx  account  for  the  hoarseness  so  common  in  secondary  syphilis. 

Affection  of  the  «  i  taneous  Appendages.    'I  he  hair  loses  its  gloss  and 

falls  out  to  a  marked  extent.  '1  he  nails  may  in  the  later  stages  be  the  seat  of 
intractable  suppurative  lesions  (paronychia)  leading  to  irregularities  in  growth. 

Am-''   riONS   ".    DEEPEB  Si  i;i  <   DTJRES.      'The   hones  are  at    first  the  seat 

neral  aching,  especially  at  night  ;  later  the  appearance  of  periosteal 
nodes,  over  the  tibia1,  frontal  and  parietal  hones.  &c,  show  thai  the  initial 
pain  was  an  early  stage  of  inflammatory  infiltration  of  the  periosteum. 

The  joints  similarly  are  the  -eat  of  pains  suggesting  rheumatism,  and 
later  transienl  synovitis  may  appear  in  several  joints. 

In  the  eye.  iritis  is  found  at  the  later  stages  of  secondary  syphilis;  the 
condition  is  similar  to  ordinary  iritis,  hut  in  addition  to  the  congestion  of  the 
iris,  contracted  pupil,  &c,  there  are  to  be  seen  small  masses  of  lymph  on  the 
front  of  the  iris  in  the  anterior  chamber,  and  at  the  margin  of  the  pupil. 
Still  later  optic-neuritis  and  choroido-retinitis  may  occur,  hut  these  should 
perhaps  rather  he  considered  as  tertiary  manifestations. 

Symmetrical  epididymitis  is  an  occasional  lesion  of  late  secondary 
syphilis.  As  has  been  mentioned  there  is  no  sharp  line  of  demarcation 
between  secondary  and  tertiary  syphilis.  The  affection  of  the  iris,  fundi, 
and  the  rupial  squamous  eruptions  and  pointed  condylomata  occur  very 
late  in  the  secondary  stage  when  definite  tertiary  lesions  in  the  form  of  gurn- 
mata  are  often  present  as  well.  Secondary  lesions  have  the  common 
characters  i  t  being  s\ mmetrical  and  of  infiltiative  character,  usually  tending 
to  heal,  seldom  leading  to  destruction  of  tissue  and  scarring. 

Tic.  DiABY  Syphilis.  The  lesions  of  this  stage  have  the  common  charac- 
teristic of  being  formations  of  granulation  tissue,  situated  asymmetrically 
and  occurring  at  times  varying  from  six  months  to  thirty  years  or  more  after 
infection.  The  fate  of  the  granulation  tissue,  thus  formed,  varies  in  some 
instances  ;  it  may  be  converted  into  fibrous  tissue  producing  sclerosis  of  the 
part  or  organ  affected,  e.g.  some  instances  of  affection  of  the  testis  :  at  other 
time.-  the  granulation  tissue  is  localized  to  form  a  tumour  or  Gumma,  and  in 
■  instances  the  fibrosis  ami  endarteritis  caused  by  the  infection,  lead  to 
a  lowering  of  the  vitality  of  the  central  part  of  such  a  gumma,  with  the 
production  of  ,i  central  slough. 

'I  he  formation  of  such  a  gummatous  tumour  is  characteristic  of  tertiary 
syphilis,  diffuse  fibrosis  is  less  common,  except  in  the  conditions  Eormerly 
known  a-  tie-  parsyphilitic  affections  of  the  nervous  system,  including  tabes 
and  genera]  paralysis  which  an-  not  considered  here. 

A  gumma  consists  of  a  mass  of  fibrosing  granulation  tissue, 
"i  firm  el.  stency,  resembling,  on  section,  a  piece  of  raw  rubber  (hence 

the  name).  The  blood-supply  of  tin- 1  amour-mass  is  not  good,  partly  owing 
to  the  contraction  of  the  organizing  fibrous  tissue  and  partly  to  the  oblitera- 
te endarteritis,  which  is  one  of  the  general  results  of  infection  with  the  spiro- 


TERTIARY  SYPHILIS  205 

chsete.  As  a  result  of  this  impoverished  blood-supply  necrosis  of  the  central 
part  of  the  gumma  takes  place  ending  in  the  formation  of  a  central,  tough, 
yellow  slough,  resembling  wash-leather  in  texture.  Gunimata  tend  to  grow 
gradually  till  they  assume  a  large  size,  and  finally  ulcerate  through  the 
skin  or  mucosa  covering  them  (e.g.  the  tongue,  testes,  &c),  when  second- 
ary infection  with  pyogenic  organisms  will  take  place.  The  slough  is 
gradually  extruded  and  healing  may  be  delayed  indefinitely.  Small  gummata 
may  heal  spontaneously,  either  before  or  after  ulceration  on  to  the  surface 
has  taken  place,  healing  being  greatly  accelerated  by  the  administration 
of  iodides  internally  ;  larger  gummata,  however,  will  be  long  in  healing  unless 
the  slough  is  first  removed.  Gummata  vary  greatly  in  size,  being  as  small 
as  a  pin's  head  in  some  instances,  or  as  large  as  a  cocoanut.  They  are,  when 
small,  commonly  multiple  and  arranged  in  groups  which  however,  if  on 
opposite  sides  of  the  body,  show  no  tendency  to  a  symmetrical  arrangement 
as  is  the  case  in  the  secondary  lesions.  Gummata  may  occur  in  any  part 
of  the  body,  but  there  are  certain  favourite  positions.  Thus  in  the  skin  they 
occur  about  the  forehead,  face,  nose,  on  the  legs  about  the  knee,  especially 
over  the  upper  end  of  the  tibia. 

The  tongue,  palate,  pharynx  and  larynx  are  common  situations,  as  well 
as  internal  organs  such  as  the  liver,  brain,  testis,  while  in  the  kidney,  stomach, 
small  intestine  they  are  so  rare  as  to  be  hardly  known. 

In  muscles  the  sternomastoid  and  masseter  are  favourite  positions. 

Gummata  are  fairly  common  in  bones,  affecting  the  vault  of  the  cranium, 
as  painful  nodes  causing  intractable  headache  ;  on  the  tibia  is  a  common 
situation. 

Clinically  gummata  appear  as  painless  (in  bone  often  painful)  lumps  or 
nodes,  well  defined  and  firm  on  palpation,  with  little  evidence  of  inflammation 
such  as  heat  or  redness,  unless  near  the  surface  and  about  to  ulcerate  through ; 
in  fact  they  closely  resemble  fibromas  except  that  they  grow  more  rapidly 
and  undergo  secondary  changes  more  speedily.  If  a  gumma  is  near  the 
surface,  in  a  few  weeks  the  skin  over  it  will  become  red  and  give  way  leading 
to  the  appearance  of  the  typical  gummatous  ulcer,  having  a  sharply  cut, 
well-defined  edge,  surrounded  by  a  slight  area  of  redness  and  infiltration  of 
minor  degree,  while  the  tough,  yellow  slough  and  absence  of  glandular 
enlargement  points  to  the  nature  of  the  condition. 

Where  a  number  of  gummata  occur  close  together  in  the  skin,  as  they 
break  down  the  resulting  ulcers  coalesce  forming  a  large  ulcer  with  scalloped 
or  "  serpiginous  "  outline,  very  characteristic  of  tertiary  syphilis.  Such 
"  serpiginous  ulcers  "  have  often  a  tendency  to  heal  in  parts  while  advancing 
elsewhere. 

Another  form  of  tertiary  syphilis  occurring  in  the  skin  is  known  as 
Syphilitic  Lupus,  from  its  resemblance  to  the  condition  of  this  name  caused 
by  infection  with  the  tubercle  bacillus.  This  occurs  in  various  situations, 
the  skin  being  infiltrated  with  granulation  tissue,  breaking  down  into  small 
ulcers  (really  very  small  gummatous  ulcers),  the  whole  area  being  of  reddish- 
br<  >wn  appearance  and  covered  with  crusts  of  dried  discharge.    The  condition 


\  TEXTBOOK  OF  SIHGERY 

[y  resembles  lupus  vulgaris,  but  advances  far  more  rapidly,  taking  months 
where  true  lupus  takes  years,  the  uodules  are  larger  and  ulceration  on  a  more 
■  ■.  This  is  a  very  important  condition  to  recognize,  since  it  yields 
quickly  to  anti-syphilitic  treatment,  while  if  treated  as  ordinary  lupus  it 
proves  most  intractable  and  advances  rapidly,  leading  to  much  scarring. 
This  last  type  of  lesion  is  also  found  in  cases  of  congenital  syphilis. 

Diagnosis  or  Gummatous  Syphilis.  The  conditions  most  likely  to  be 
confused  with  gummata  are  sarcomas  and  carcinomas.  From  sarcoma 
diagnosis  is  needed  in  the  earlier  stages,  while  the  gumma  is  still  unbroken, 
and  in  many  instances  this  is  extremely  difficult,  especially  where  the  lesion 
is  deep-seated  in  bone  or  viscera.  The  history  of  past  syphilis  and  the  presence 
of  a  positive  Wassermann  reaction  will  be  helpful,  as  well  as  the  reaction  to 
antisvphilitic  remedies,  while  the  local  incidence  of  tumours  and  syphilitic 
lesions  in  special  regions,  will  be  of  assistance  and  is  detailed  under  the 
differential  diagnosis  of  diseases  of  different  regions  and  organs.  Not 
infrequently,  however,  exploration  is  necessary  and  this  should  always  be 
done  early,  where  there  is  any  doubt  as  to  the  nature  of  a  swelling,  since  if  the 
condition  proves  not  to  be  a  sarcoma,  clearing  away  the  slough  of  a  large 
gumma  is  quite  sound  treatment.  When  a  gumma  has  burst  on  the  surface 
it  may  resemble  an  epithelioma,  and  the  differential  diagnosis  is  considered 
in  the  section  on  Disease  of  the  Tongue,  Testis,  &c;  suffice  it  here  to  mention 
that  gummatous  ulcers  are  not  indurated  to  any  great  extent,  are  not 
adherent  to  surrounding  structures,  possess  in  the  early  stages  the  character- 
istic wash-leather  slough  in  the  centre,  and  are  not  associated  with  enlarge- 
ment of  the  appropriate  lymph  nodes. 

The  formation  of  granulation  tissue  in  tertiary  syphilis,  which  does  not 
terminate  in  gummata  but  in  fibrosis,  comes  less  into  surgical  cognizance 
than  does  gummatous  formation.  It  is.  however,  noteworthy  as  the  under- 
lying cause  of  arterial  degeneration,  leading  to  the  formation  of  aneurysms, 
and  is  the  basis  of  glossitis,  both  superficial  and  interstitial .  which  is  a  frequent 
precursor  of  squamous-celled  cancer  of  the  tongue,  and  therefore  a  condition 
of  paramount  importance. 

The  highly  important  later  results  of  spirochetal  infection,  tabes, 
ral  paralysis,  &c.,  which  have  till  recently  been  classed  together  as 
•  parasyphilis,  "  are  described  in  works  on  internal  medicine  and  neurology. 
genital  Syphilis.  By  this  term  is  understood  a  syphilitic  infection 
of  the  foetus  in  utero,  and  it  is  of  little  moment  whether  the  mother  was 
infected  in  the  act  oi  coitus,  which  led  to  conception,  before  this  or  later, 
since  there  seems  to  be  no  doubt  that  the  foetus  can  be  and  actually  does 
become  infected  by  Bpirochsetes  traversing  the  placenta  from  the  maternal 
to  the  foetal  circulation.  This  previous  infection  of  the  mother  (before 
the  birth  of  the  child)  explains  the  phenomenon  known  as  Colles's  law, 
viz.  that  an  infanl  suffering  from  congenital  syphilis  never  infects  its  mother 
by  suckling  though  it  may  readily  infect  a  wet  nurse  ;  for  the  simple  reason 
that  the  disease,  though  possibly  producing  no  obvious  lesion,  is  present  in 
the  mother.     As  the  infection  is  directly  into  the  blood  there  is  naturally 


CONGENITAL  SYPHILIS  207 

no  primary  stage,  but  the  disease  starts  as  a  generalized  infection.  The 
results  vary  greatly,  often  the  virulence  of  the  infection  destroys  the  foetus 
early  in  its  career  and  miscarriage  results.  This  may  be  repeated  several 
times  till  the  virulence  is  diminished  and  a  foetus  survives  and  is  viable  but 
still  infected.  There  is  no  need  to  dwell  on  these  still-born  catastrophes, 
interesting  as  they  are  pathologically,  but  we  may  turn  at  once  to  the  results 
on  living  children.  The  infant  may  be  born  with  manifest  lesions  in  the  skin , 
&c. ;  more  commonly  it  appears  normal  at  birth  and  only  develops  signs  of 
syphilis  after  a  few  weeks  or  months,  and  if  the  virulence  has  been  much  at- 
tenuated, some  years  may  elapse  before  any  indications  of  the  disease  appear. 
The  early  manifestations  may  be  compared  with  those  of  secondary  or 
generalized  syphilis,  those  developing  later  to  the  tertiary  lesions  of  the 
acquired  disease.  The  first  effects  of  the  spirochsete  are  noted  in  about  two 
months  after  birth,  and  are  situated  in  the  skin  and  mucous  membranes 
just  as  in  the  acquired  variety. 

The  nasal  and  pharyngeal  mucosa  are  the  seat  of  an  intractable  catarrh 
which  causes  the  "  snuffles,"  difficulty  in  sucking,  and  hoarseness  of  the  cry, 
so  often  found  in  these  cases.  Such  "  snuffles  "  must  not  be  confounded 
with  an  ordinary  coryza,  or  nasal  catarrh,  which  may  affect  quite  small 
infants  with  or  without  the  presence  of  adenoid  vegetations.  In  addition 
to  "  snuffles  "  cutaneous  rashes  appear,  especially  on  the  palms,  soles, 
buttocks,  and  about  the  mouth.  The  rash  is  papular  and  of  the  red-brown 
colour  noted  in  secondary  syphilis,  and  may  become  pustular,  squamous  or 
bullous  (formation  of  large  blisters  or  bullae);  desquamation  of  the  epithelium 
from  these  lesions  leads  to  raw  areas  or  superficial  ulcers  about  the  mouth 
(rhagades),  which  leave  superficial  scars  and  are  good  evidence  in  either 
condition  of  present  or  past  syphilis.  Together  with  these  cutaneous  lesions 
the  general  health  becomes  impaired,  the  infant  becoming  weak,  wasted,  and 
marasmic  to  a  marked  degree  ;  the  skin  is  wrinkled  (from  loss  of  fat),  brownish 
or  earthy  in  hue,  and  the  whole  aspect  is  ancient  and  wizened.  Anaemia  is 
considerable  and  the  liver  and  spleen  are  enlarged  :  death  often  occurs  in  this 
stage.  If  under  treatment  or  owing  to  the  infection  being  mild  the  infant 
survives  this  stage,  later  lesions  appear  in  the  bones,  joints,  eyes,  &c.  As 
the  result  of  the  nasal  inflammation  spreading  deeper,  necrosis  and  mal- 
development  of  the  septum  nasi  occurs,  which  is  noted  from  the  depression 
of  the  bridge  of  the  nose  (saddle  nose).  Sometimes  there  is  an  inflammatory 
overgrowth  of  the  bones  surrounding  the  anterior  fontanelle  (frontals  and 
parietals),  causing  this  aperture  to  be  surrounded  by  four  bosses,  giving  the 
"  cross  bun  "  effect  to  the  skull.  Sometimes  subacute  suppurative  lesions 
appear  at  the  ends  of  the  long  bones,  about  the  epiphyseal  line,  apparently 
due  to  a  pyogenic  infection  on  a  preliminary  syphilitic  lesion  (epiphysitis, 
periostitis  or  pseudoparalysis  of  infants.     (See  Diseases  of  Bones.) 

Sometimes  the  skull  is  thin  in  parts  and  atrophic,  like  parchment,  readily 
indenting  on  quite  gentle  pressure  (craniotabes).  These  bone-lesions  occur 
during  the  first  and  second  years  of  life,  though  the  depression  of  the  nose 
will  not  be  noted  till  later,  since  the  nose  of  infants  is  normally  without 


A  TEXTBOOK  OF  SURGERY 


much  bridge.  At  this  period  occurs  also  syphilitic  enlargement  of  the  testis, 
leading,  as  a  rule,  to  fibrous  atrophy  of  the  organ.  After  the  first  year 
ordinary  tertiary  lesions  are  found,  viz.  gummata  of  the  tongue,  testis.  &c, 
though  these  are  noi  so  very  common.  More  usual  are  lesions  of  bones, 
joints,  teeth,  and  eyes  winch  usually  appear  between  live  and  fifteen,  but  may 
be  delayed  till  early  adult  life. 

The  characteristic  deformity  of  the  teeth  in  congenital  syphilitica  is 
known  after  its  discoverer  as  ••  Hutchinson's  teeth."  The  deformity  consists 
in  malformation  of  the  incisors  and  bicuspids,  which  assume  irregular  and 

'"  peg-shaped"  appearance,  but  the 
most  typical  feature  and  the  only 
one  on  which  reliance  for  diagnosis 
is  to  be  placed,  is  an  absence  of  the 
central  cusp  on  the  cutting  edge  of 
the  upper  central  incisors,  which 
gives  the  tooth  a  curious  notched 
appearance.  The  permanent  teeth 
only  are  affected,  hence  the  condi- 
tion is  not  found  before  seven  years 
of  age.    (Fig.  68.) 

Later  Lesions  of  Bones.  This 
is  usually  a  sclerosis  with  some 
curvature,  and  the  bones  most  com- 
monly affected  are  the  tibiae  (sabre- 
tibia1).  Less  often  the  lesion  is  one 
of  rarefaction,  sometimes  with  for- 
mation of  gummata.  affecting  the 
long  bones  or  the  metacarpals  and 
metatarsals,  in  the  latter  instances 
producing  conditions  closely  resemb- 
ling tuberculous  dactylitis. 

Late    Affections    of    Joints. 
fourt.cn  months.  A    symmetrical    painless    synovitis 

occurs,  most  commonly  in  the  knees, 
with  formation  of  granulations  in  the  interior  of  the  synovial  membrane, 
which  in  many  instances  is  very  refractory  to  treatment. 

Affections  of  the  Eye.  The  most  usual  is  the  occurrence  of  inter- 
stitial keratitis,  in  which  there  is  an  infiltration  of  the  cornea,  which  becomes 
grey  and  "  steamy  "  and  later  slightly  uneven  on  the  surface,  giving  the 
effect  of  ■'  ground  glass,"  associated  with  much  photobia,  lacrymation,  and 
circumcornea]  congestion.  Still  later  there  is  an  ingrowth  of  vessels  from 
the  corneo-sclerotic  junction  into  the  cornea,  which  becomes  vascularized, 
and  the  red  patches  resulting  are  known  as  "  salmon  patches."  This  con- 
dition talo-s  long  to  clear  up  and  permanent  opacities  often  remain.  Iritis 
and  choroiditis  may  also  occur  either  alone  or  with  keratitis,  but  are  less 
common. 


Fig.  67.     Periostitis  ol  upper  end  of  ulna 
due  to  congenita]  syphilis,  in  infanl 


DIAGNOSIS  OF  GENERALIZED  SYPHILIS  209 

Of  affections  of  the  ear,  internal  ear  deafness  sometimes  results  from 
congenital  syphilis. 

Diagnosis  of  Generalized  Syphilis.  The  diagnosis  of  primary 
syphilis  has  already  been  considered  as  well  as  some  points  in  the  diagnosis 
of  gummatous  lesions.  It  now  remains  to  discuss  the  question  of  deciding 
if  a  given  lesion  be  due  to  generalized  syphilis,  whether  congenital  or 
acquired.  The  personal  history  will  often  be  of  help  ;  in  men  the  account 
of  a  hard  chronic  sore,  associated  with  an  indolent  bubo,  protracted  tonsillitis, 
various  cutaneous  rashes,  loss  of  hair  and  bone -pains  of  rheumatic  nature, 


Fir:.  68.     Congenital  syphilis  (set.  10),  showing  well-marked  notching  of  the  upper 
central  incisor  teeth  (Hutchinson's  teeth). 

are  suggestive  ;  but  unless  carefully  cross-examined  a  history  of  what  was 
really  a  soft  sore  or  even  an  attack  of  gonorrhoea  may  be  mistaken  for  one  of 
syphilis.  In  a  woman  or  the  wife  of  a  male  patient,  in  addition  to  some  of  the 
above  affections,  there  may  be  a  history  of  repeated  miscarriages,  followed 
by  birth  of  living  children,  the  earlier  of  which  suffered  from  snuffles, 
rashes  and  malnutrition,  perhaps  dying  after  a  few  months,  which  is  strong 
evidence  of  syphilis  ;  too  much  stress,  however,  must  not  be  laid  on  occasional 
miscarriages,  as  these  are  not  infrequent  incidents  of  sexual  life,  arising  from 
all  manner  of  causes  apart  from  syphilis.  The  patient  may  carry  evidence  of 
past  syphilis  on  his  or  her  person,  such  as  a  depressed  nose,  a  chronic  ulcera- 
tive condition  with  necrosis  of  the  interior  of  the  nose  (sometimes  wrongly 
called  cezena  from  the  foul  smell  present),  scars  of  gummatous  ulcers  on  the 
forehead,  nose  (well  healed,  more  or  less  circular,  depressed,  areas  of  thin 
i  14 


A  TEXTBOOK  OF  SURGERY 

ai  tissue),  similar  -  gummata  about  the  knees, 

old  scars  and  loss  of  substance  of  the  palate  and  fauces,  chronic  laryngitis  and 

nd  contracture  of  this  region.     -  the  skin 

cted  from  their  diversity  of  form  (polymorphic),  viz.  papules,  pustules, 

bulla    -  us.  rupia,  &c.,  whereas  cutaneous  lesions  of  other  origin  usually 

-  Mie  one  type  {e.g.  eczema,  psoriasis,  lichen  planus,  &c.) ;  this 
and  their  colour  of  copper  or  lean  ham.  their  being  non-irritative,  and  that 
they  are  associated  with  a  general  state  of  malnutrition,  pains  in  the  bones 
and  joints,  will  make  d:  3  as  fairly  certain.  In  early  lesions  the  presence  of 
the  spirochete  in  scrapings  may  decide  the  matter.     The  crucial  tot  at 

:it  is  the  presence  of  a  positive  Wassermann  reaction  in  the  serum. 
When  present  it  is  practically  conclusive  that  syphilis  is  present  though 

bly  latent.  Absence  of  the  reaction  may  be  because  the  disease  is 
earlv  (it  does  not  appear  for  about  three  weeks  after  the  appearance 
of  the  primarv  chancre),  and  it  may  disappear  for  a  while  and  then  be  found 
that  a  single  negative  reaction  is  of  little  value  in  excluding  later 
svphilis.  If  the  reaction  is  absent  in  patients  who  are  still  syphilitic,  the 
reaction  mav  be  made  to  reappear  by  an  injection  of  salvarsan,  and  this 
'"  provocative  injection  ;:  is  of  considerable  use  in  deciding  the  question  :  if 
the  reaction  is  negative  on  several  occasions,  after  such  a  provocative  injec- 
tion of  salvarsan.  it  will  be  tolerably  certain  that  the  patient  is  not  affected 
with  syphilis.  Lately  Xoguchi  has  introduced  a  cutaneous  reaction  with  a 
substance  called  "  Luetin."  which  is  an  extract  of  cultures  of  the  spirocl 
emploved  like  the  von  Pirquet  tuberculin  reaction.  In  normal  subjects 
ervthema  only  results,  but  in  syphilitica  a  crop  of  papules  and  pustules  appears. 
This  reaction  is  said  to  be  more  obvious  in  late  tertiary  cases  than  in  active 
primarv  or  secondary  conditions,  which  is  the  reverse  of  the  Wassermann 

•ion.     If  this  be  the  case  the  reaction  should  be  most  useful.     Finally 
it  must  be  remembered  that  the  presence  of  syphilitic  infection  does  not 

-<arilv  imply  that  the  lesion  under  consideration  is  due  to  this  disease  ; 

it  may  be  of  totally  different  origin  or  it  may  be  a  sequel  of  syphilis  but  of 

quite  a  different  order,  e.g.  a  squamous-celled  cancer,  originating  in  a  tongue 

which  is  affected  with  syphilitic  glos  dlarly  a  syphilitic  patient  may 

a  cancer  of  th< 

S  aital  syphilis  is  to  be  suspected  in  the  presence  of  some  of  the 

us  already  mentioned,  of  which  the  most  notable  are  the  saddle 
the  rhag.;  ira  about  the  mouth,  the  bossed  forehead,  and  the  notched 

•    .   while  interstitial  keratitis  is  practically  conclusive  of  con- 

•  al  syphilis.     In  the  absence  of  these  signs  the  later  lesion  of  bones  or 
joints  may  be  hard  to  diagnose  without  an  early  personal  or  family  history, 
but  either  the  "Wassermann  or  the  Luetin  reaction  should  be  positive. 
-.     Even  with  imperfect  treatment  the  immediate  pi 

bills  in  the  acquired  variety  is  not  bad.  though  occasionally  the  secondary 

.  it  syphilis),  and  carries  off  the  patient 
from  severe  anemia,  phagedenic  ulceration,  &c.  The  mortality  of  infants 
from  the  congenital  variety  must  be  far  higher,  since  we  have  little  know- 


ENTFECTIVITY  OF  SYPHILIS  211 

ledge  of  the  number  which  die  prematurely  of  the  disease  and  are  miscarried, 

as  well  as  a  fair  number  which  are  born  alive  and  developing  severe  les 
in  the  first  few  months  die  in  spite  of  treatment. 

The  late  results  of  the  disease  are  at  present  less  amenable  to  treat- 
ment, though  here  the  more  serious  lesions,  tabes,  cerebral  syphilis, 
come  into  the  hands  of  physicians  and  neurologists,  forming  a  considerable 
percentage  of  the  hopeless  cases  of  infirmaries  and  asylums.  The  tertiarv 
lesions  of  severe  type  coming  into  surgical  hands  are  aneurysms  and  cerebral 
tumours  (gummata).  neither  of  which  are  very  common.  With  the  recent 
advances  in  treatment  these  late  and  fatal  effects  of  the  spirochete  will 
probably  be  to  a  great  extent  obviated. 

Ixfectivity  of  Syphilis.     This  varies  with  the  stage  of  the  dise 
being  very  Lfreat  in  the  primary  and  secondai  e   s,  from  the  local  les 

which  swarm  with  spirochetes,  but  quite  low  in  tertiarv  conditions,  though 
the  spirochetes  are  fairly  numerous  in  these  as  well.  It  was  formerly  be- 
lieved that  tertiary  lesions  were  non-infective,  but  in  light  of  the  discovery 
of  the  spirochetes  in  all  manner  of  tertiary  lesions,  this  view  seems  scarcely 
tenable  ;  still  there  is  no  doubt  that  their  power  of  infection  diminishes 
greatly  in  the  later  stages  of  the  disease.  Infectivity  with  regard  to  sexual 
life  is  of  the  highest  importance.  Although  conception  by  a  syphilitic- 
woman  for  the  first  few  months  or  years  after  infection  will  almost  infallibly 
lead  to  the  production  of  a  syphilitic  foetus,  yet  after  some  time,  although  the 
patient  is  not  cured  and  may  show  tertiary  lesions,  a  normal  progeny  may  be 
produced.     In  th>-  the  disease  is  sufficiently  latent  not  to  be  able 

to  pass  through  the  placenta.  The  presence  of  a  positive  Wassermann  does 
not  necessarilv  imply  that  the  patient  can  infect  by  sexual  i 

It  is  generally  agreed  that  patients  who  have  been  imder  mercurial 
treatment  for  a  period  of  two  years,  without  showing  any  siims  of  active 
disease,  are  so  unlikely  to  infect  their  consorts  that  marriage  maybe  allowed. 
AVith  the  advance  of  our  knowledge  of  the  results  of  treatment  with  salvarsan 
and  its  allies,  the  time  necessary  to  wait  will  probably  be  shortened,  but 
further  facts  are  necessary  before  we  can  dogmatize  on  this  most  important 
point. 

Treatment  of  Syphilis.  Prophylaxis.  This  has  been  discussed  by 
moralists,  eugenjsts,  experts  in  public  health  and  others  at  great  le  _ 
the  points  chieflv  at  issue  being  the  regulation  of  prostitution,  and  the  noti- 
fication of  syphilis,  as  of  other  important  contagions  diseases.  Much  may 
id  on  both  sides,  and  the  discussion  lies  outside  the  scope  of  a  work  on 
practical  surgery.  We  might,  however,  put  forward  a  plea  for  the  better 
education  of  youth  in  sexual  matters,  and  especially  with  regard  to  sexual 
ne  and  the  possibilities  incurred  in  lapses  from  virtue,  and  how  such 
possibilities  may  be  prevented  or,  if  present,  suspected  in  their  earlier  s*  g  - 
This  is  no  place  to  moralize  on  the  original  sins  of  mankind,  if  sins  they  be. 
which  are  also  the  fundamental  cause  of  perpetuation  of  the  race.  Contin- 
ence, that  counsel  of  perfection,  is  good,  but  if  mortals  should  lapse  from 
virtue,  it  is  better  that  they  should  run  as  little  risk  as  possible  of  being 


212  \  TEXTBOOK  OF  SURGERY 

infected  with  a  disease,  which  may  not  only  last  the  off ender  f or  many  years, 

and  whose  Bequelse  are  legion,  bul  may  also  be  handed  on  to  perfectly  innocent 

tates  and  offspring.     However  wrong  such  departures  from  the  path 

tricl  morality  may  be,  the  results  of  infection  with  the  gonococcus  or 
spirochsete  are  Ear  worse,  and  if  we  consider  the  possibilities  of  infecting 
other  harmless  persons,  to  regard  the  disease  as  a  suitable  punishment  is 
simply  ludicrous.  Instruction  as  to  the  importance  of  simple  cleanliness  of 
the  genitals  after  coitus  would  go  far  to  prevent  these  infections,  and  the  use 
of  Buitable  antiseptic-  such  as  calomel  ointment  30  per  cent.,  and  protargol 
injection  10  percent.,  will  render  infection  almost  impossible.  If  these  pre- 
cautions were  widely  adopted  venereal  disease  could  be  well  nigh  stamped 
out. 

rativi  Tn  atnu  nt  of  Syphilis.  Three  types  of  drug  are  of  use  in  syphilis. 
Compounds  of  arsenic  and  mercury  actually  destroy  the  spirochetes,  the 
former  rapidly,  the  latter  more  slowly  (some  deny  that  mercury  destroys 
the  parasites,  maintaining  that  its  only  action  is  to  assist  in  the  healing  of 
the  lesii  iodides  simply  promote  the  absorption  of  fibrous  and  granula- 

tion tissue  in  tertiary  gummatous  formations.    In  addition  local  treatment  is 
"d  in  cases  where  there  is  formation  of  ulcers  or  gummata  not  yielding 
readily  to  general  measures,  or  of  large  size,  or  in  important  situations,  e.g. 
gummata  of  the  brain. 

Arsenic.  This  drug  was  originally  given  in  the  form  of  simple  salts, 
alternating  with  mercury,  but  it  has  been  found  that  if  arsenic  is  com- 
bined in  organic  compounds  much  larger  doses  may  be  given  with  impunity, 
producing  great  destruction  of  the  parasites.  The  arylarsonates  were 
formerly  used,  but  these  have  been  entirely  eclipsed  in  effect  as  wTell  as  in 
safety  of  action  by  the  drugs  investigated  by  Ehrlich,  who  discovered  that 
when  combined  with  benzene  derivatives  arsenic  has  an  extraordinarily 
hthal  effect  on  certain  pathogenic  organisms,  especially  spirilla,  while  the 
toxic  effect  of  the  drug  on  the  patient  is  extremely  slight.  In  fact  it  was 
thought  at  first  that  a  dose  could  be  safely  given  large  enough  to  destroy 
all  the  organisms  present  in  the  blood  and  tissues,  without  producing  much 

•on  on  the  part  of  the  patient.  This  method  of  producing  internal 
asepsis  with  regard  to  the  organisms  in  question  was  described  by  Ehrlich 
as  "therapia  sterilans  magna."  The  method  has  proved  very  efficacious 
though  not  quite  so  Bweepingly  curative  as  this  name  would  imply,  since 
relapses  occur  in  a  certain  proportion  of  cases  :  nevertheless  the  results  are 
-'i  good  an<l  so  rapidly  obtained  that  the  use  of  neosalvarsan  bids  fair  to 
exclude  that  of  other  drugs  as  the  main  stand-by  in  case  of  generalized 
syphilis. 

A  further  important  effect  of  neosalvarsan  is  that  alter  its  use  there  is  a 
great  destruction  ol  the  organisms  in  the  cutaneous  lesions,  so  that  patients 
are  either  no  longer  infective,  or  their  danger  in  this  respect  is  greatly 
led  need,  so  thai  the  drug  is  of  greal  value  in  prophylaxis. 

ob  606,  and  Neosalvarsan.    The  former  is  described  in 
chemical  terms  as  dioxy-diamido-arsenobenzol,  the  latter  is  a  derivative 


TREATMENT  OF  SYPHILIS  213 

from  salvarsan,  having  less  toxicity  but  requiring  to  be  given  in  larger  doses  ; 
0-6  of  a  gramme  of  salvarsan  or  606  is  equivalent  to  09  of  a  gramme  of 
neosalvarsan. 

The  drug  is  given  by  intravenous  injection  dissolved  in  150  c.c.  of  sterile 
distilled  water  or  normal  saline  solution.  Water  should  be  re-distilled  shortly 
before  use  to  prevent  the  occurrence  of  rigors,  depression,  &c,  which  may  result 
if  old  distilled  water  is  used,  presumably  from  the  toxins  of  dead  bacteria  in 
such  water.  Various  techniques  are  used  for  injection,  a  tolerably  fine 
needle  is  inserted  straight  into  a  vein  at  the  bend  of  the  elbow,  made  promin- 
ent by  bandaging  the  arm  above  :  the  fluid  is  forced  in  by  gravity  with  a 
funnel  and  long  tube,  or  by  some  pneumatic  apparatus  such  as  that  of  Fildes 
and  Mackintosh.  Recently  the  drug  has  been  given  in  a  more  concentrated 
form,  dissolved  in  10  c.c.  distilled  water  with  an  antitoxin  syringe.  The  plan 
is  simpler  and  the  results  are  said  to  be  just  as  good  as  when  given  in  the  larger 
bulk  and  greater  dilution.  The  injected  fluid  must  be  cold  and  the  drug 
dissolved  immediately  before  injection  to  prevent  decomposition  taking 
place.  If  a  vein  cannot  readily  be  entered  with  the  needle  through  the  skin, 
as  in  small  children  or  where  the  veins  are  small,  buried  under  fat,  it  will 
be  necessary  to  cut  down  and  find  the  vein  by  dissection. 

Opinions  differ  as  to  the  number  of  doses  to  be  given,  and  the  intervals 
which  should  elapse  between  each  injection.  Three  injections  of  0'9  gramme 
neosalvarsan  given  in  ten  days  may  be  taken  as  a  fair  average  for  cases  in  the 
secondary  stage,  more  is  required  in  old-standing  tertiary  conditions.  Local 
lesions  disappear  rapidly  after  injection  and  the  serum  reaction  becomes 
negative,  but  may  become  positive  again  after  some  months,  in  which  case 
it  is  uncertain  whether  we  should  persist  with  neosalvarsan  or  put  the  patient 
on  a  long  course  of  mercury.  It  is  probably  wiser  in  most  instances  after 
administering  salvarsan  to  keep  the  patient  on  mercury  as  well  for  some 
time. 

Neosalvarsan  and  salvarsan  are  contra-indicated  in  renal  disease,  diabetes, 
and  severe  cerebral  syphilis.  Their  use  is  questionable  in  severe,  generalized 
syphilis  of  the  "  malignant  "  type,  though  in  some  instances  they  are  most 
efficacious  in  such  cases.  In  tertiary  conditions  complete  cure,  i.e.  rendering 
negative  the  Wassermann  reaction,  is  less  usual  than  in  the  earlier  stages, 
but  the  drug  is  useful  in  promoting  healing  of  the  local  lesions,  where  iodides 
are  no  longer  efficacious.  We  have  already  mentioned  the  use  of  an  injection 
of  neosalvarsan  in  diagnosis,  since  in  suspected  cases  where  the  Wassermann 
reaction  is  negative  a  single  dose  of  the  drug  will  often  cause  the  reaction  to 
become  positive,  and  this  "  provocative  injection  "'  is  of  use  in  obscure 
cases. 

Mercury.  Before  the  introduction  of  salvarsan,  mercury  was  the  sheet- 
anchor  in  the  treatment  of  syphilis  and  is  still  of  great  value.  This  drug  can 
be  administered  in  many  different  ways  ;  by  the  mouth,  skin  or  by  intra- 
muscular injections. 

(1)  Administration  of  Mercury  by  Mouth.  Several  preparations  are 
used,  various  authorities  claiming  special  merits  for  each  ;    as  a  matter  of 


214  A  TEXTBOOK  OF  SURGERY 

fact,  pracl  ice  w  it  h  each  plan  will  give  good  results,  as  the  dosage  and  duration 
ol  administration  vary  with  indh  idual  i  s 

iiiw  powder  in  doses  ol  1  to  2  grains,  combined  with  pulv.  ipecach.  co. 
it\  the  form  of  Hutchinson's  pill,  ot  the  ]»ill  hydrarg.,  used  in  similar  manner 
ami  quantity,  is  given  three  times  a  day.  Some  prefer  the  iodide  of  mercury  ; 
a  convenient  manner  of  prescribing  this  is  to  give  one  half  to  one  dram  of 
the  liquor  hydrargr.  perchlor.  with  ten  grains  of  potassium  iodide,  which  is 
useful  for  tertiary  lesions,  but  may  affect  the  digestion  if  given  over  long 
periods.  In  all  cases  where  mercury  is  given  over  long  periods,  by  any 
method,  the  mouth  should  be  overhauled  by  a  dentist  at  the  commencement 
of  the  course,  carious  teeth  removed  or  filled,  tartar  removed  and  instruction 
in  the  use  of  the  toothbrush  given  if  necessary.  If  these  precautions  be  not 
taken  severe  mercurial  stomatitis  may  occur.  The  course  of  mercury  should 
extend  over  two  years,  bui  with  intermissions,  when  signs  of  mercurialism 
occur,  such  as  salivation,  sponginess  of  the  gums,  stomatitis,  colic  and 
diarrhoea.  During  intermission  of  mercurial  treatment  iron  tonics  should 
be  prescribed. 

(2)  Administration  of  Mercury  by  the  Skin.  Mercurial  ointment  may 
be  rubbed  into  the  skin  of  the  axilla  and  groins,  a  dram  at  a  time,  every  night, 
using  a  different  place  for  inunction  on  each  occasion  till  signs  of  mercurialism 
appear  ;  when  the  inunctions  should  be  less  frequent. 

The  patient  may  be  exposed  naked  to  vaporising  calomel  and  water 
vapour  daily  for  half  an  hour  till  signs  of  mercurialism  appear.  Administra- 
tion by  the  skin  is  perhaps  less  likely  to  upset  the  digestive  functions  than 
it  the  drug  be  given  by  mouth,  but  even  if  this  method  be  employed  the 
mouth  must  be  attended  to  carefully  before  commencing  treatment. 

(3)  Mercury  has  been  given  largely  in  military  and  naval  practice  in  the 
form  of  "  grey  oil  "  injected  into  the  muscles  of  the  buttock.  Grey  oil  is  an 
emulsion  of  metallic  mercury  in  a  mixture  of  lanoline  and  liquid  paraffin, 
in  t  he  strength  of  one  grain  metallic  mercury  to  ten  minims  of  the  emulsion  : 
this  is  injected  with  aseptic  precaution  into  the  muscles  of  the  buttock,  one 
grain  of  mercury  weekly  for  about  six  doses,  and  the  course  is  repeated 
half  yearly  for  two  years. 

The  injection  may  cause  much  pain,  and  abscesses  occasionally  develop, 
while  if  the  patient  is  over-susceptible  to  mercury  and  becomes  poisoned 
the  mercury  is  not  easy  to  remove  from  the  system.  A  course  of  injections 
with  grey  oil  is  often  used  alter  a  course  of  aeosalvarsan,  and  has  the  greal 
advantage  over  administration  by  mouth,  that  much  less  time  is  occupied 
in  the  process  and  the  practitioner  is  certain  that  mercury  actually  reaches 
the  interior  of  his  patient. 

Iodides.  These  are  given  as  solution  of  potassium  or  sodium  iodide,  the 
latter  being  less  depressing,  and  further  to  counteract  the  depressing  effect 
of  the  drug,  carbonate  of  ammonia  may  be  given,  5  to  10  grains  with  each 
of  iodide.  The  dose  of  iodide  varies  from  10  to  90  grains  three  times 
;  daw  and  is  used  in  tertiary  lesions.  As  it  has  no  curative  effect  on  the 
disease  but.  only  promotes  absorption  of  gummata,  iodide  should  be  combined 


LOCAL  TREATMENT  OF  SYPHILIS  215 

with  mercury  or  neosalvarsan,  administered  at  the  same  time.  The  un- 
pleasant taste  when  large  doses  are  given  may  be  diminished  by  giving 
each  dose  in  half  a  pint  of  milk. 

Treatment  of  Congenital  Syph  His.  Mercury  may  be  given  freely  to  infants 
in  the  form  of  grey  powder,  half  a  grain  three  times  a  day,  or  inunction  of 
mercurial  ointment  may  be  employed.  Gummatous  lesions  may  be  treated 
with  mercury  and  iodides  as  in  adults.  Neosalvarsan  can  be  employed  in 
the  later  lesions  of  congenital  syphilis  affecting  the  cornea,  bones  and  joints, 
but  its  use  in  small  infants  may  be  attended  with  danger,  besides  being  difficult 
to  administer  from  the  smallness  of  the  veins. 

Local  Treatment  of  Syphilis.  In  the  primary  stage  it  will  often  be 
necessary  to  lay  open  the  prepuce,  if  tight,  to  prevent  the  spread  of  ulceration 
of  a  concealed  chancre  and  permit  of  the  application  of  antiseptic  dressings. 
Usually  the  primary  lesion  is  dressed  with  mercurial  lotion  in  the  form  of 
"  black  wash,"  but  there  is  no  reason  to  believe  that  this  is  superior  to  ot  her 
antiseptics,  as  the  amount  of  mercury  absorbed  in  this  manner  must  be  very 
minute. 

Where  the  chancre  is  of  the  ordinary  type  a  dusting  powder  of  zinc  oxide, 
boric  acid  and  calomel  may  be  used  ;  where  the  condition  is  sloughy,  boric 
fomentations,  dilute  lysol  hip-baths,  irrigation  with  peroxide  of  hydrogen, 
and  even  painting  with  pure  carbolic  may  be  employed.  Excision  of  chancres 
seems  to  be  useless.  Under  adequate  specific,  i.e.  anti-syphilitic  treatment, 
the  local  lesions  usually  heal  rapidly  if  kept  surgically  clean.  Gummata,  if 
disclosed  at  exploratory  operations,  should  be  scraped  out,  sutured  and 
drained  for  a  few  hours,  in  a  similar  manner  to  that  employed  in  the  treat- 
ment of  cold  abscesses,  while  specific  treatment  is  at  once  adopted.  To 
sum  up,  most  cases  of  generalized  syphilis  should  be  treated  with  neosalvarsan, 
if  the  practitioner  has  had  opportunities  of  learning  the  intravenous  technique 
ancl  the  effect  of  treatment  should  be  controlled  by  observing  the  serum- 
reaction  at  regular  intervals.  Three  doses  should  be  given  in  about  ten  days 
followed  by  a  course  of  intramuscular  injections  of  mercury  or  mercury 
should  be  given  by  mouth  for  six  months.  If  the  reaction  remain  positive 
after  this  time  a  further  course  of  neosalvarsan  should  be  given  and  the 
mercurial  course  repeated.  Where  salvarsan  is  contra-indicated  or  the  prac- 
titioner is  not  used  to  the  intravenous  technique  (which  is  not  difficult  to 
learn),  mercury  should  be  given  over  long  periods  (two  years  or  more  with 
intermissions). 

With  regard  to  cure  Hutchinson  found  that  70  per  cent,  of  cases  of 
early  generalized  syphilis,  treated  with  mercury  by  mouth,  gave  a  negative 
Wassermann  reaction  after  two  years  of  treatment,  but  after  one  year  only 
10  per  cent,  were  cured,  i.e.  the  method  is  very  slow.  The  results  after 
intramuscular  injections  of  mercury  were  less  good,  only  45  per  cent,  having 
a  negative  serum  reaction  after  two  years.  According  to  Harrison  the  best 
results  are  those  after  the  use  of  neosalvarsan  ;  for  more  than  80  per  cent,  of 
such  cases  were  cured  after  two  years,  taking  a  negative  Wassermann 
reaction  as  the  index  of  cure. 


216  A  TEXTBOOK  OF  SURGERY     . 

Thus  neosalvarsan  not  only  cures  a  greater  percentage  of  cases,  but  also 
has  the  advantage  of  effecting  the  cure  much  more  rapidly,  and  so  not 
only  tends  to  prevent  patients  from  contaminating  others  with  the  disease, 
but  will  probably,  in  the  future,  prevent  the  later  lesions  of  the  spirochaete 
on  the  nervous  and  vascular  systems,  which  are  at  present  so  potent  in 
increasing  the  mortality  of  this  protracted  and  fell  disease. 

In  the  tertiary  stage  complete  cure  is  less  easy.  Local  lesions  and  even, 
at  times,  parasyphilitic  conditions  clear  up  under  iodides,  mercury  and,  above 
all.  neosalvarsan  ;  but  even  after  many  injections  of  the  latter  drug  the 
Wassermann  reaction  may  still  be  positive,  indicating  that  though  the 
patient  may  be  no  longer  infective  to  others  he  may  still  develop  the  lesions 
of  parasyphilis. 

YAWS  OR  FRAMBCESIA 

This  disease,  which  occurs  in  the  West  Indies  and  tropical  Africa,  is  due  to 
a  spirochaete,  and  in  many  respects  resembles  syphilis. 

The  parasite  causing  the  disease  is  closely  allied  to  that  of  syphilis,  but 
whether  it  is  a  variation  of  the  latter  or  a  distinct  species  is  at  present  un- 
certain. Like  syphilis  there  is  a  primary  sore,  and  after  some  weeks  there 
arises  a  generalized  "  secondary  "  eruption  in  the  form  of  papules  scattered 
over  the  body,  which  later  become  patches  of  granulation  tissue  not  unlike 
raspberries  in  appearance  (whence  the  name).  Later  ulcerative  lesions 
allied  to  gummata  may  appear.  Neosalvarsan  is  even  more  efficacious  in 
this  disease  than  in  syphilis. 

(6)  Fungi  and  Yeasts  of  a  pathogenic  nature  such  as  those  producing 
ringworm,  thrush,  blastomycetic  dermatitis,  &c,  need  no  further  mention 
here. 

(7)  Infections  with  Metazoan  Parasites.  Parasitic  worms  are  the 
most  important  of  the  metazoan  parasites.  Several  types  are  of  surgical 
interest.  Thus  of  the  Flukes,  Bilharzia  Haematobia  is  described  in  the  section 
on  Urinary  Surgery  ;  of  the  nematodes  a  possible  cause  of  appendicitis  is  the 
Thread- worm  mentioned  in  the  section  on  the  Surgery  of  the  Abdomen  ; 
infection  with  the  Filaria  is  mentioned  in  the  section  on  Lymphatics.  There 
remain  to  be  considered  the  cestodes  or  tapeworms,  of  which  the  variety 
of  main  surgical  interest  is  the  Taenia  Echinococcus,  the  cause  of  hydatid 
disease. 

HYDATID  OR   ECHINOCOCCUS  DISEASE 

The  adult  worm,  taenia  echinococcus,  inhabits  the  intestine  of  the  dog,  but 
is  seldom  found,  being  small  and  with  only  four  segments  to  its  body. 
The  ova  are  discharged  from  the  intestine  of  the  dog  and  arrive  in  the  in- 
testine of  man  presumably  on  raw  vegetables  such  as  watercress.  In  the 
intestine  the  ova  develop  into  a  free  swimming  embryo  with  a  circle  of  hooks 
and  suckers  on  its  head.  This  creature  bores  its  way  through  the  intestinal 
wall  and  enters  the  blood-vessels  or  peritoneal  cavity,  and  thus  arrives 
in  the  liver,  muscles,  brain,  kidney,  &c.  Having  arrived  at  a  suitable  place 
the  embryo  takes  up  its  abode  there  and  develops  into  a  cyst,  consisting 


HYDATIDS 


217 


of  an  external  lamellated.  chitinous  ectocyst,  and  an  internal  soft  living 
protoplasmic  endocyst ;  outside  the  whole  parasite  is  a  fibrous  capsule 
formed  by  the  inflammatory  reaction  of  the  tissues  of  the  host.  Inside  the 
cyst  is  a  clear  fluid  having  a  specific  gravity  of  1005.  The  hydatid  cyst  then 
grows  in  size  and  may  undergo  further  development.  From  the  lining  proto- 
plasmic membrane  secondary  cysts  may  develop,  and  inside  these  again 
other  cysts,  so  that  the  original  cyst  is  full  of  translucent  spheres  of  varying 
size.  From  the  inside  of  the  original  cyst  or  the  insides  of  its  daughter  or 
descendant  cysts  there  develop  buds  which  are  each  surrounded  with  a 


Fig.  69.     Scolices  and  hooklets  from  a  hydatid  cyst  (magnified). 


crown  of  hooks  and  suckers,  and  are  the  heads  or  scolices  of  the  future  genera- 
tion of  worms,  and  these  develop  no  further  in  the  body  of  the  host  until  such 
time  as  this  is  perchance  partaken  of  by  a  dog.  Sometimes  the  cysts  are 
barren,  producing  no  daughter  cysts  or  scolices  (acephelocysts).  In  other 
instances  the  secondary  cysts  are  formed  exogenously  by  budding  on  the 
outside  of  the  primary  cyst,  and  thus  a  collection  of  cysts  without  a  common 
shell  is  formed. 

Changes  in  Hydatid  Cysts.  (1)  The  organism  may  die  and  be  con- 
verted, by  calcification,  into  a  mortary  mass. 

(2)  The  cyst  may  burst  usually  into  some  body  cavity  with  varying 
results,  such  as  being  coughed  up  from  the  lung  or  causing  peritonitis 
if  bursting  into  the  peritoneum,  while  urticaria  often  follows  on  this 
accident. 

(3)  Suppuration  may  occur  around  a  hydatid  cyst  from  secondary 
infection. 

This  disease  is  not  common  in  this  country  though  frequent  in  Iceland, 
Australia,  &c.     In  the  body  the  most  common  situation  for  hydatid  cysts  is 


\  TEXTBOOK  OF  SURGERY 

the  liver,  after  this  the  other  abdominal  organs,  including  the  bladder  and 
kidney,  less  often  in  the  lungs  and  pleura. 

i  hese  parasites  develop  painlessly  unless  suppural  ion  occurs,  and 
nt  the  characters  of  slow-growing  cysts  which,  it  noted  in  the  liver,  are 
likely  to  be  suspected  of  being  hydatids,  especially  if  eosinophilia  be  present 
as  well.  The  so-called  hydatid  fremitus,  which  is  supposed  to  be  felt  on  per- 
cussion,  from  a  shaking-up  of  the  daughter  cysts,  is  a  purely  mythical  phe- 
nomenon, and  the  sensation  while  percussing  over  a  hydatid  differs  in  no 
way  from  that  produced  in  other  collections  of  fluid.  Suppuration  around 
a  hydatid  cyst  will  give  the  usual  Hydatid  disease  is 

further  discussed  under  the  surgery  of  the  Liver. 


SECTION  II 

SURGERY    OF  THE   SKELETOMOTOR 
SYSTEM 

In  this  section  are  included  injuries  and  diseases  of  bones,  joints, 
muscles,  tendons  and  bursae,  including  deformities.  It  is  conve- 
nient to  consider  injuries  of  this  system  first  and  diseases  later  ; 
injuries  of  the  spine  are  considered  under  the  nervous  system 
with  which  they  have  more  in  common,  while  diseases  of  the  spine, 
forming  a  part  of  orthopaedic  surgery  and  having  little  effect  on  the 
nervous  system  in  most  instances,  are  considered  at  the  end  of  the 

present  section. 

CHAPTER  XI 

INJURIES   OF  THE   SKELETOMOTOR   SYSTEM   (GENERAL) 

Lijuries  of  Bones  :  Contusions  :  Fractures  :  Varieties  and  terms  :  Separated 
epiphyses  :  General  pathology  of  fractures  and  their  repair  :  Signs  :  General 
results  of  fractures  :  Treatment  in  general  :  First-aid  :  Reduction  :  Non- 
operative  treatment  :  Extension  :  Fixation  :  Splints  :  Plaster  :  Indications  for, 
and  methods  of,  operative  treatment  :  Obstacles  to  reduction  :  Massage  : 
Complications  of  fractures  :  Compound  fractures  :  Complications  with  joints. 
vessels,  nerves  :  Xon-union  and  mal-miion  :  General  complications  :  Pneu- 
monia :  Crutch  palsy. 

Injuries  of  joints  :  Sprains  :  Wounds  :  Dislocations  :  Causes  :  Reduction  of 
dislocations  and  difficulties. 

Rupture  of  muscles  and  tendons  :  Dislocation  of  tendons  :  Ischaemic  con- 
tracture of  muscles. 

It  is  proposed  to  consider  in  this  chapter  fractures  and  other  injuries  of 
bones  as  well  as  similar  affections  of  joints,  muscles,  tendons,  and  bursae, 
dealing  with  the  general  effects  of  injury  on  these  structures. 

INJURIES   TO   BONES 

Under  this  heading  are  comprised  (1)  Contusions  and  (2)  Fractures. 

(1)  Contusions  of  Bones.  Contusion  or  bruising  of  bones  and  their 
periosteal  covering  are  usually  of  slight  moment  and  arise  from  injuries 
of  insufficient  violence  to  produce  fracture.  Severe  contusions  may,  how- 
ever, cause  effusion  of  blood  under  the  periosteum,  of  such  magnitude,  that 
the  blood  is  not  absorbed  before  new  bone  is  laid  clown  by  the  periosteum, 
which  has  been  raised  by  the  effused  blood,  leading  to  a  prominent  enlarge- 

219 


\  TEXTBOOK  OF  SURGERY 

ment  of  the  bone  which  may  be  of  greal  size  and  Buggesl  the  formation  <>i  a 
n.'w  growth. 

nosis.  This  is  easily  made  in  the  more  superficial  bones  from  the 
presence  of  a  tender  swelling  on  the  hone  at  the  site  of  injury,  in  which 
fluctuation  may  be  detected  it  there  is  much  blood  effused. 

Treatment.  Rest  and  firm  bandaging  for  the  first  forty-eight  hours 
to  Lessen  the  effusion  followed  by  massage  to  assist  the  removal  of  the 
extravasated  blood,  [fa  large  subperiosteal  hsematoma  has  formed,  aseptic 
incision  and  evacuation  of  the  clot  will  afford  the  most  speedy  and  certain  cure. 

Sequela.  Subacute  osteitis  and  periostitis  are  not  uncommon,  the 
lump  or  node  on  the  hone  persisting  for  several  months  but,  as  a  rule,  sub- 
Biding  gradually.  Acute  suppurative  osteitis  and  periostitis,  from  blood- 
borne  infection  of  the  extravasated  blood,  usually  with  pyogenic  cocci,  may 
occur,  especially  if  there  is  any  abrasion  over  the  contusion.  In  such  cases 
there  will  be  a  sudden  access  of  fever,  the  temperature  rising  to  102°  to  KM  ; 
the  swelling  will  become  very  tender  and  the  skin  over  it  red,  tense  and 
boggy.  Suppuration  of  such  subperiosteal  hematomas  is  fairly  common  on 
the  front  of  the  tibia. 

Treatment,  incision  and  drainage  will  usually  result  in  speedy  cure;  if 
there  is  local  death  of  the  bone,  in  the  affected  area,  the  dead  part  or  seques- 
trum will  need  removal  at  a  later  date,  if  it  does  not  become  absorbed  or 
separated  readily. 

(2)  Fractures.  A  fracture  may  be  defined  as  an  interruption  in  the 
continuity  of  a  bone  arising  suddenly  from  force  acting  within  or  without  the 
body. 

Fractures  may  arise  in  normal  or  diseased  bones  ;  the  violence  necessary 
to  cause  fracture  in  some  of  the  latter  conditions  may  be  quite  trifling 
To  fractures  of  this  sort  the  name  "  spontaneous  fractures  "  or  fractures  from 
disease  is  given,  i.e.  the  diseased  condition  is  the  more  important  factor  in 
the  lesion. 

Causation.  The  immediate  causes  of  fractures  may  be  placed  in  two  main 
groups. 

(1)  Direct  Violence,  in  which  a  bone  breaks  at  the  site  of  application  of 
violence,  e.g.  when  a  wheel  passes  over  the  leg. 

(2)  I  mined  Violence,  when  the  fracture  does  not  take  place  at  the  point  of 
application  <>1  the  violence  ;  force  is  applied  to  an  osseo-ligamentous  system. 

and  this  give8  way  at  its  weakest  point,  e.g.  when  ;,  patient  tails  heavily  on 
the  outstretched  hand,  the  radius  may  be  fractured,  the  elbow  dislocated, 
or  the  humerus  or  clavicle  fractured  or  dislocated.  All  these  are  examples  of 
fractures  or  dislocations  by  indirect  violence.  A  variety  of  fracture  by  in- 
direct violence  is  that  due  to  muscular  effort,  e.g.  when  the  humerus  is 
fractured  by  throwing  a  cricket  ball. 

A  further  division  can  be  made,  according  to  the  manner  in  which  the 
force  is  applied,  into  tension,  bending,  crushing,  torsion  violence,  &c. 

^Etiology  of  Fractures.  Ayr  and  tier.  Fractures  are  more  common 
m  men  than  women,  on  accounl  of  the  greater  exposure  of  the  formerto 


FRACTURES 


221 


injuries  in  the  course  of  their  occupations.  But  the  skill  attained  by  men  in 
avoiding  injuries  during  adult  life  makes  them  less  liable  to  fractures  in  old 
age  than  women  :  this  explains  the  greater  preponderance  of  Colles's  frac- 
tures in  women  after  middle  life.  In  infants,  after  the  danger  of  the  ac- 
coucheur is  escaped,  fractures  are  uncommon,  owing  to  the  care  taken  in 
their  supervision  ;  but  in  young  children,  especially  boys,  fractures  are  rela- 
tively common  from  their  natural  tendency  to  adventurous  enterprises. 

Morbid  conditions  of  the  bones  are  important  predisposing  causes,  viz.  : 

(a)  Atrophy  of  bone  whether  due  to  old  age  or  nervous  disease  such  as 
tabes,  general  paralysis,  and  lunacy. 

(6)  Fragilitas  ossium,  a  rare  congenital  condition,  the  cause  of  which  is 
unknown,  but  which  is  evidenced  by  the  repeated  recurrence  of  fractures, 
usually  in  children. 

(c)  Local  disease  of  bone  is  the  most  important  of  all,  because  a  fracture 


% 


I  \ 


a  o  c  d  e 

Fig.    70.     Varieties   of   fracture,     a,   Oblique.     /;,    Transverse,     c,   Comminuted. 
d,  Partial  or  green-stick,     e,  Double  fracture. 

may  be  the  earliest  sign  of  malignant  disease  of  bone  and  is  often  over 
looked  at  the  commencement.     Of  such  conditions  we  find  : 

(1)  Local  inflammations,  as  chronic  osteomyelitis,  gummata,  &c. 

(2)  Primary  giant-celled  and  round-celled  sarcomas. 

(3)  Secondary  cancer  of  the  breast,  thyroid,  prostate,  &c. 

Varieties  of  Fractures  and  Definitions  of  the  Terms  Employed. 
Fractures  are  further  distinguished  according  to  their  relation  to  the  surface 
of  the  body,  their  extent,  the  condition  and  shape  of  the  fragments,  &c,  as 
follows  : 

(1)  A  closed,  simple,  or  subcutaneous  fracture  is  one  in  which  there  is  no 
open  wound  of  the  skin  and  tissues  leading  down  to  the  site  of  fracture, 
and  in  which  there  is  no  gross  lesion  of  the  surrounding  tissues  (note,  perfectly 
simple  fractures  are  not  very  common  ;  as  a  rule  there  is  some  injury  to  sur- 
rounding muscles,  tendons,  blood-vessels,  &c.  which,  though  perhaps  of 
minor  degree,  yet  maybe  sufficient  to  prevent  a  perfect  result). 


\  TEXTBOOK  OF  SURGERY 

An  open  or  compound  Eracture  is  one  which  communicates  with  the 
side  world  by  a  wound  in  the  surrounding  tissues  and  skin  or  mucosa. 
\  i  omplicated  Eracture  is  one  in  which  other  severe  injuries  are  asso- 
ciated with  the  osseous  lesion,  e.g.  injury  t«>  a  large  vessel,  nerve,  joint,  or  an 
important  viscus  such  as  the  rectum.  Lung,  or  if  the  Eracture  is  associate!  I  with 
a  dislocation  of  a  joint  in  close  proximity. 

(  h  The  term  complete,  when  applied  to  a  fracture,  needs  no  explanation, 
i.k  or  incomplete  fractures  occur  in  the  soft bones  of  children  ; 
the  hone  being  partly  broken  and  partly  bent. 

(6)  A  comminuted  or  splintered  fracture  is  one  in  which  there  are  several 
smallish  fragments,  while  the  term  multiple  fracture  is  applied  to  cases  in 
which  there  are  two  or  more  distinct  fractures  in  the  same  bone  which 
do  not  communicate  with  cadi  other. 

(7)  The  direction  of  the  line  of  fracture  gives  rise  in  several  terms  : 

(a)  Transverse  or  straight  across  the  long  axis  of  the  bone  :  mostly  from 
direct  violence. 

(6)  Oblique  and  spiral,  where  indirect  or  torsion-violence  has  been 
applied.  Pure  oblique  and  long  spiral  fractures  are  less  common  than  an 
asymmetrical  oblique  type  in  which  the  line  of  fracture  is  slightly  spiral. 
These  are  often  described  as  "  en  bee  de  Flute,"  and  occur  typically  in  the 
middle  of  the  tibia. 

(c)  Longitudinal  splits  of  bones  are  not  common. 

(d)  T-  or  Y-shaped  fractures  are  a  combination  of  a  longitudinal  with 
atrai  ractureand  are  therefore  comminuted  :  these  are  usually  found 
at  the  lower  ends  of  the  humerus  and  femur,  passing  into  the  elbow  and 
knee-joints. 

(e)  Stellate  fractures  are  comminuted,  and  the  lines  of  fracture  radiate 
from  a  common  centre;  these  occur  in  the  patella,  and  skull  from  direct 
violence. 

(J)  Impacted  fractures  are  where  one  fragment  is  driven  into  the  other ; 
the  upper  end  of  the  femur  and  humerus  are  usual  sites  for  this  type  of 
fracture.      (Fig.  71.) 

{<D  Depressed  fractures,  where  one  fragment  is  driven  lower  than  the 
other,  are  found  mosl  notably  in  the  skull. 

(A)  Punctured  fractures  are  a  variety  of  depressed  fracture  caused  by 
impact  of  a  pointed  object,  e.g.  a  bullet  or  spike. 

[ntra-uterine  fractures  occur  during  foetal  existence  in  utero. 
■    <  'ongenital  fractures  occur  during  birth  usually  from  some  manipula- 
tion on  the  part  of  the  accoucheur,  rendered   necessary  by  difficulty  in 
delivery. 

Epiphyseal  injuries  and  separation  of  epiphyses  form  an  important 
group  of  fractures,  whether  from  traumatic  or  pathological  causes.  Separa- 
tion of  aii  epiphysis  usually  takes  place  through  the  spongy,  growing  bone  at 
the  end  of  the  diaphvsis.  immediately  belowthe  epiphyseal  cartilage,  which 
is  fixed  more  firmly  to  the  epiphysis.  In  young  children,  in  whom  the  whole 
epiphysis  is  formed  oi  cartilage,  a  pure  separation  often  occurs.     In  older 


SEPARATION  OF  EPIPHYSES 


223 


children,  in  whom  the  epiphysis  is  large]}-  bony,  the  direction  of  .separation 
passes  in  part  along  the  epiphyseal  line,  but  in  most  instances  deviates  from 
this  into  the  diaphysis,  and  a  portion  of  the  end  of  the  latter  is  torn  away  with 
the  epiphysis.  The  periosteum  is  but  loosely  attached  to  the  diaphysis 
though  firmly  fastened  to  the  epiphyseal  cartilage,  and  thus  is  dragged  off 
with  the  latter,  forming  a  sort  of  "  sleeve,"  which  is  a  great  source  of  difficult v 
in  reducing  the  displacement  of  the  epiphysis. 

After  reduction  of  a  separated  epiphysis  there  is  usually  no  interference 
with  growth  of  the  part,  but  in  some  instances  growth  is  inhibited  or  may 
cease.  Such  interference  with  growth  is  of  special 
importance  at  the  lower  end  of  the  forearm  or  leg 
(usually  from  injury  to  the  lower  epiphysis  of  the 
tibia  or  radius),  since  the  relative  overgrowth  of 
the  uninjured  epiphysis  causes  a  deviation  of  the 
hand  or  foot,  which  in  the  examples  quoted  would 
be  to  produce  a  condition  of  Varus  (see  Affections 
about  the  ankle). 

It  is  probable  that  slight  injuries  about  the 
epiphyseal  line,  not  sufficient  to  produce  separa- 
tion, though  causing  some  effusion  of  blood  and 
lymph  which  is  described  hypothetically  as 
juxta- epiphyseal  strain  (Oilier),  are  responsible  for 
the  incidence  of  acute  infective  disease  in  these 
parts,  since  such  inflammations  originate  in  the 
diaphyseal  side  of  the  epiphvseal  cartilage,  and  a   Fig.  71.    Impacted  fracture ; 

,.,.«.  riii  11  -i         the  neck  of  the  femur  driven 

slight  effusion  of  blood  may  well  serve  as  a  nidus  jnt0  jts  shaft. 

for  any  organisms  circulating  in  the  blood. 

General  Pathology  of  Feactures  and  their  Repair.  The  process 
of  repair  in  fractured  bones  is  analogous  to  that  of  wounds  and  injuries  of 
soft  parts,  viz.  the  formation  of  granulation  tissue  and  the  cicatrization  of 
this  ;  but  the  process  goes  further  and  the  cicatrix  is  converted  into  bone. 
At  the  time  of  fracture  there  is  a  tearing  of  blood-  and  lymph-vessels  with 
outpouring  of  blood  and  lymph,  so  that  the  ends  of  the  bones  lie  embedded 
in  a  mass  of  coagulated  blood  and  lymph,  the  torn  vessels  gradually  throm- 
bose, and  in  one  to  three  days  the  effusion  ceases  to  increase. 

The  ends  of  the  fragments  are  rough  and  irregular  and  often  connected 
together  to  a  varying  degree  by  a  "  bridge  "  of  periosteum,  which  plays  an 
important  part  in  the  process  of  repair.  In  simple,  fissured  or  split  fractures 
and  partial  fractures  with  no  separation  of  the  fragments  the  periosteum  is 
almost  intact  and  union  occurs  rapidly,  whereas  in  complete  fractures  with 
much  separation  of  the  fragments,  due  to  great  violence  (and  such  fractures 
are  often  compound),  the  stripping  of  periosteum  is  much  greater  and  the 
connecting  "  bridge  "  may  be  minimal  or  absent.  In  such  cases  the  union 
is  much  slower,  this  being  one  of  the  reasons  for  the  retarded  union  of  com- 
pound and  complicated  fractures. 
.  As  soon  as  the  haemorrhage  has  ceased,  the  phenomena  of  reparative 


224 


\  TEXTBOOK  OF  SURGERY 


inflammation  soon  come  into  play.  The  mass  of  coagulated  blood  and  lymph 
is  invaded  by  leucocytes  from  the  blood,  and  migrating  tissue-cells  from 
the  periosteum  and  hone,  which  become  bypersemic  and  (edematous.  The 
invading  cells  remove  the  clol  and  any  small  fragments  of  bone  which  may 
be  separated  from  their  periostea]  connexion  and  so  are  ill  a  dying  condition. 
Capillary  loops  grow  into  the  mass  from  the  surrounding  vessels  and  some  of 
the  cells  which  have  immigrated  into  the  scene  of  action,  change  from  the 
round  to  a  spindle  shape,  and  begin  to  form  connective  tissue.  So  far  the 
changes  resemble  those  occurring  in  the  formation  of  granulation  tissue,  but 


a  b  o 

Fig.  ~-.     Onion  of  fractures,     a,  Where  position  is  good,  showing  the  small  amount 

of  definitive  callus  (black),     b.  Whore  the  position  is  not  «ood  ;   much  more  callus. 
which  becomes  rounded  off  later  (c). 


the  cells  derived  from  the  bone  and  periosteum  have  the  property  of  laying 
down  rudimentary  hone  in  the  intercellular  substance,  and  this  stiffens 
and  hardens  the  granulation  tissue,  which  is  given  the  name  of  "  provisional 
callus.'"  and  forms  the  initial  bond  of  union  between  the  ends  of  the  fragments. 
For  descriptive  purposes  this  alius  is  divided  into  (I)  ensheathing  callus. 
which  surrounds  the  ends  of  the  fragments,  like  the  solder  used  by  plumbers 
in  joining  two  lead  pipes,  and  (2)  the  medullary  plug,  or  internal  callus, 
which  is  formed  in  the  medullary  cavity  between  the  ends.  The  bone  of 
provisional  callus  is  soft,  spongy  and  irregular  in  texture,  and  during  its 
formation,  areas  of  cartilage  or  a  substance  closely  resembling  this  are  found 
scattered  through  the  callus.  The  cells  forming  the  callus  are  derived 
largely  from  the  periosteum,  but  also  from  the  hone  itself  and  perhaps  the 
medulla  as  well.  In  addition  to  the  external  and  internal  callus  new  bone 
is  also  formed  directly  between  the  ends  of  the  fragments;  this  is  known 
as  definitive,  true  or  permanent  callus,  and  forms  rather   later  than   the 


REPAIR  OF  FRACTURES  225 

provisional  callus,  being  of  denser  nature  and  more  regular  in  texture  and 
possessing  Haversian  canals  and  systems  like  ordinary  dense  bone.  Finally  the 
ensheathing  callus  and  medullary  plug  are  absorbed,  and  the  bone  assumes 
its  normal  shape,  if  the  ends  are  in  good  position,  being  now  joined  by  strong 
permanent  callus.  As  regards  time,  the  blood  clot  is  absorbed  in  a  week  or 
two  according  to  the  amount  extravasated.  The  provisional  callus  com- 
mences to  form  in  about  the  same  time,  while  definitive  callus  commences 
a  few  days  later.  The  ensheathing  callus  is  fully  developed  in  three  to  nine 
weeks  according  to  the  patient's  age  and  the  bone  broken,  and  is  strong 
enough  to  stand  ordinary  strains  to  which  the  bone  may  be  subjected.  The 
final  stage  takes  two  to  six  months.  Naturally  repair  takes  place  more 
rapidly  in  children  than  adults,  and  must  be  further  advanced  in  the  leg  than 
the  arm  before  use  of  the  limb  is  permitted,  owing  to  the  greater  strains  to 
which  the  former  is  subjected.  When  the  fragments  are  not  in  good  appo- 
sition, i.e.  when  the  ends  are  separated,  the  amount  of  provisional  callus 
is  greater  and  no  definitive  callus  is  formed,  but  the  ensheathing  and  medul- 
lary callus  become  stronger  where  the  strain  is  greatest,  and  gradually  form 
dense  compact  buttresses  of  bone  firmly  uniting  the  fragments.  In  such 
cases  there  is  absorption  both  of  the  callus  and  the  unnecessary  parts  of  the 
ends  of  the  fragments  as  well,  so  that  finally  nature  makes  a  fairly  neat  job  of 
what  is,  to  begin  with,  somewhat  of  a  bungle. 

Examination  and  Diagnosis  of  Fractures.  In  examining  a  patient 
suspected  of  fracture  care  must  be  taken  that,  while  manipulating  the 
part,  matters  are  not  made  worse,  e.g.  by  converting  a  closed  into  an  open  or 
compound  fracture.  A  preliminary  palpation  through  the  clothes  may 
reveal  gross  deformity  or  it  may  be  noted  at  a  glance,  e.g.  that  the  feet  point 
backwards,  rendering  the  presence  of  fracture  somewhere  tolerably  certain. 
Clothes  are  to  be  removed  with  the  greatest  care,  always  unclothing  the 
sound  limb  first,  and  if  there  is  any  difficulty,  slitting  up  the  seam  of  the 
garment  on  the  injured  side.  The  history  of  something  giving  way  with  a 
snap  followed  by  pain  may  be  suggestive,  though  often  misleading,  as  in  the 
case  of  a  fisherman  who  fell  off  a  high  wall  while  in  the  pursuit  of  his  avoca- 
tion ;  he  heard  a  loud  snap  and  felt  a  great  pain  in  his  knee.  Further  investiga- 
tion, however,  revealed  that  it  was  a  landing-net,  and  not  his  knee,  which  had 
sustained  the  fracture.  The  pain  may  be  described  as  grinding  or  grating 
(subjective  crepitus),  or  that  the  limb  feels  as  though  falling  to  pieces. 

Physical  Signs.  In  all  cases  the  injured  should  be  compared  with  the 
sound  side  :  some  of  the  following  signs  will  be  elicited. 

A.  Local  Signs.  (1)  Local  trauma,  viz.  swelling  and  infiltration  of  the 
part,  bruising  and  discoloration,  hematoma,  or  blebs.  These  condition-;  are 
most  marked  where  a  bone  has  been  broken  near  the  surface,  e.g.  the  tibia 
and  patella. 

(2)  Deformity,  which  may  be  so  gross  as  to  be  detected  through  the 
clothes  or  absent,  in  case  of  linear  and  subperiosteal  fractures,  or  very  slight 
and  difficult  to  detect,  as  in   some    impacted  fractures.     Deformity  may 
be  in  several  directions, 
i  15 


\  TEXTBOOK  OF  SURGERY 

(a)  Longitudinal  deformity  may  be  in  the  direction  of  lengthening  or 
shortening;  in  the  former  instance  by  separation  <>!  the  fragments,  e.g. 
in  fractures  of  the  patella  ;  in  the  latter  the  condition  may  be  from  overriding 
as  in  oblique  fractures,  or  impaction  of  the  smaller  into  the  larger  fragment. 
Entudinal  deformity  is  determined  with  the  tap  s  measure,  by  estimating 
the  distance  between  two  definite  bony  points  one  above  the  lesion,  the 
other  below,  and  comparing  this  with  the  measurement  on  the  sound  side. 

(6)  Angular  deformity,  when  the  axis  of  the  lower  fragment  is  not  continu- 
ous with  that  of  the  upper  fragment,  but  forms  an  angle  with  it  ;  the  apex 
of  the  angle  may  form  a  visible  or  palpable  projection. 

(c)  Lateral  when  the  ends  are  side  by  side  without  overlapping. 

((f)  Rotary,  when  the  lower  fragment  is  rotated  on  its  long  axis,  with 
ect  to  the  upper  fragment. 

(e)  Elevation  or  depression  may  occur  in  fractures  of  flat  bones  as  the 
skull  and  scapula. 

The  causes  of  deformity  are  : 

(1)  The  original  violence  causing  the  fracture. 

Forces  applied  to  the  loose  fragments  after  fracture  has  occurred, 
such  as  : 

(a)  The  weight  of  the  limb. 

(6)  Muscular  spasm,  which  must  be  obviated  in  treatment  by  a  proper 
arrangement  of  the  limb,  massage,  &c. 

(c)  Unskilled  manipulation  may  increase  the  deformity  already  present. 

Deformity  is  usually  greatest  in  fractures  due  to  indirect  violence,  i.e. 
oblique  fractures,  and  less  in  the  transverse  variety. 

(3)  Unnatural  Mobility,  i.e.  movement,  can  be  produced  in  the  length  of 
the  bone  by  firmly  grasping  its  two  ends  and  attempting  to  bend  it.     When 

lit  this  is  a  most  important  sign ;  it  is  not  easy  to  obtain  when  a  fracture 
ar  the  end  of  the  bone  and  is  not  present  when  the  fracture  is  impacted 

i  n'  subperiosteal.     Once  this  test  has  proved  the  presence  of  fracture  it  should 

not  be  used  again  owing  to  the  pain  produced. 

(4)  Loss  of  Function  is  usually  a  marked  sign,  particularly  when  a  bone 
unsupported  by  a  neighbouring  bone  is  fractured.  Loss  of  function  may  be 
slight  when  one  of  two  parallel  bones  is  broken,  e.g.  the  fibula,  and  in  some 
instances  of  impacted  fracture. 

(5)  Crepitus.  By  this  term  is  meant  the  palpable  and  sometimes 
audible  grating  caused  by  the  movement  of  the  rough  ends  of  the  fragments 
on  each  other.  Like  unnatural  mobility  this  sign  is  not  to  be  elicited  too 
freely,  for  the  patient's  sake.  Crepitus  is  absent  in  subperiosteal  and  im- 
pacted fractures. 

The  bony  crepitus  of  fracture  is  to  be  distinguished  from  crepitus  arising 
from  oth(  such  as  from  effusion  of  blood  or  air  into  the  tissues  or  of 

lymph  into  tendon  Bheaths.     When  noted  in  such  conditions  crepitus  is  of  a 
c  and  finer  quality  than  that  due  to  the  grating  of  fragments  of  bone. 
A  form  of  crepitus  very  closely  resembling  that  noted  in  fractures  occurs  in 
joints  where  the  articular  cartilage  has  been  worn  off  the  ends  of  the  bones 


DIAGNOSIS  OF  FRACTURES  227 

(osteoarthritis),  and  hence  the  surfaces  in  apposition  arc  bony.  This  form  of 
crepitus  can  at  times  be  distinguished  only  with  difficulty  from  that  found  in 
fractures.  This  adds  to  the  difficulty  in  diagnosing  obscure  lesions  about  the 
hip.  a  joint  especially  prone  to  osteo-arthritis. 

(6)  Local  Tenderness,  i.e.  pain  at  the  seat  of  fracture  caused  by  manipula- 
tions, will  be  noted  in  testing  for  unnatural  mobility  and  crepitus,  and  may  be 
present  when  these  signs  are  absent.  In  cases  of  subperiosteal  fracture,  it 
may  be  the  only  sign,  except  the  X-ray  investigation.  Tenderness  will  be 
experienced  by  direct  pressure  over  the  fracture,  but  this  might  also  be  due  to 
a  contusion  of  the  bone.  A  better  method  of  employing  this  test  is  to  attempt 
to  bend  the  bone,  and  sec  if  the  patient  feels  extra  pain,  when  this  is 
attempted  at  the  supposed  seat  of  fracture. 

(7)  X-ray  pictures  form  an  important  adjunct  to  the  accurate  diagnosis 
and  treatment  of  fractures  ;  moreover,  in  these  days  of  litigation  they  are 
of  value  as  evidence  in  law  courts. 

Some  fractures  can  hardly  be  diagnosed  without  the  help  of  X-rays,  e.g. 
subperiosteal  or  fissured  fractures,  or  those  involving  small  bones  as  the 
carpal  scaphoid,  or  small  fragments  of  bone  as  the  coracoid,  coronoid,  &c. 
At  the  same  time,  though  important,  this  is  by  no  means  the  only  method  of 
use  in  diagnosis,  and  cases  must  not  be  merely  referred  to  an  X-ray  expert, 
but  thoroughly  examined  by  eye,  hand  and  tape  measure  first.  Moreover,  the 
interpretation  of  X-ray  pictures  of  bones  needs  considerable  experience,  the 
appearance  of  normal  bones  and  their  lines  of  contour  must  be  well  known. 
the  date  of  ossification  and  junction  of  epiphyses  remembered,  and  the  dis- 
tortion caused  by  the  method  taken  into  account.  Deformity  nearly  always 
appears  worse  in  X-ray  negatives,  if  taken  in  two  planes,  than  is  found  to  be 
actually  the  case  at  operation.  The  X-ray  is  also  most  important  in  judging 
the  effects  of  treatment  and  deciding  whether  the  effect  of  splinting  is 
sufficiently  good  or  whether  operative  attacks  will  be  needed. 

(8)  Finally,  anaesthesia  is  often  of  use  for  the  more  thorough  investigation 
of  fractures  and  also  is  most  convenient  and  necessary  in  many  cases  for 
treatment.  Diagnosis  of  fractures  will  be  further  discussed  under  injuries 
of  special  regions. 

B.  General  Results  of  Fractures.  These  may  be  so  slight  as  to  be 
negligible  or  so  severe  as  to  rank  as  complications  rather  than  mere  general 
effects.     The  following  are  fairly  common. 

(1)  Shock.  This  varies  in  degree,  depending  on  the  size  and  number  of 
hones  broken  and  still  more  to  the  relation  of  the  fractured  bone  to  important 
structures,  such  as  the  brain,  spinal  cord,  lungs,  abdomen  and  pelvis. 

(2)  Fever  usually  occurs  even  in  simple,  closed  fractures,  probably  from 
the  absorption  of  the  effusion  about  the  fragments.  The  temperature  is 
rarely  over  101°  and  is  of  no  importance.  In  cases  of  compound  fracture 
severe  fever,  due  to  septicaemia,  may  arise. 

(3)  Delirium  is  tolerably  common  in  even  moderate  drinkers,  but  as  a 
rule  is  hardly  of  such  severity  as  to  merit  the  name  of  "  delirium  tremens," 
except  in  confirmed  tipplers  or  where  the  lesion  is  very  severe. 


A  TEXTBOOK  OF  S1RGERY 

lism.  By  this  term  is  implied  a  passage  of  small  fat- 
globules  fn>in  thf  injured  medulla  of  the  bom1,  at  the  site  of  fracture,  into 
the  veins,  and  so  to  the  lungs  and  brain.  This  probably  occurs  to  a  minor 
degree  in  many  cases,  but  w  ith  slight  results.  In  severe  instances,  however, 
the  pulmonary  or  cerebral  circulations  may  be  so  blocked  by  numerous 
small  fat  emboli  that  the  functions  of  these  organs  are  seriously  interfered 
with  and  dyspnoea  or  coma  may  arise,  sometimes  terminating  fatally. 

General  Treatment  of  Fractures.  Our  object  in  the  treatment  of  a 
fracture  is,  as  far  as  possible,  to  restore  the  limb  or  part  where  the  fracture 
0  enrs  to  its  normal  condition,  i.e.  restoration  of  function  is  our  goal.  It  is 
i  aportant  to  bear  this  in  mind  and  not  to  allow  mere  restoration  of  the 
anatomical  form  of  the  bone  (although  in  itself  an  important  factor  in 
Treatment)  to  loom  too  large  upon  our  horizon. 

Of  late  years  two  new  lines  of  thought  have  come  into  our  ideas  con- 
cerning the  best  treatment  of  fractures,  which  it  must  be  admitted  had  been 
previously  somewhat  relegated  to  the  background  owing  to  the  advances 
in  abdominal  surgery.  These  two  lines  of  treatment  are  largely  associated 
with  the  names  of  Lucas  Champoniere  and  Lane — the  former  being  the 
protagonist  of  the  school  of  massage  and  movement,  the  latter  of  the  opera- 
tive technique  in  the  treatment  of  fractures.  The  former  school  advocates 
the  restoration  of  function  by  massage  and  movement,  both  active  and 
. -e.  leaving  the  adjustment  of  the  fragments  to  take  care  of  itself  ; 
the  latter  aims  at  accurate  anatomical  apposition  of  the  fragments,  main- 
taining that  this  is  the  all-important  desideratum,  and  is  only  possible  by 
open  operation. 

Tie-  practical  surgeon  will  try  to  avail  himself  of  the  good  points  of  these 
divergent  schools,  combining  them  with  the  older  methods  of  reduction, 
splinting  and  extension,  and  treating  each  case  on  its  merits.  For  there  can 
o  doubt  that  many  fractures  can  be  treated  by  massage  alone,  while 
others  must  be  operated  on  if  we  are  to  avoid  functional  disaster,  and 
others  again  can  be  Treated  withr  eduction  and  splints,  followed  by  massage, 
and  give  very  perfect  functional  results.     Briefly,  massage  is  beneficial  to  all 

tures  at  some  part  of  their  course;  some  require  splinting  or  open 
operatiou  in  addition,  while  others  may  be  treated  with  massage  alone. 

First-Aid.  The  main  object  of  first-aid  is  to  avoid  rendering  a  fracture 
worse  during  transport  to  the  scene  of  treatment,  i.e.  preventing  the  jagged 
end-  of  the  bones  from  lacerating  the  skin  or  important  structures  such  as 

els  or  nerves  and  bo  leading  to  complications.  This  may  usually  be 
avoided  by  traction  on  the  limb,  along  its  axis,  and  fixing  temporarily  t  > 
some  improvised  splint  such  as  umbrellas,  rolled  newspapers,  padded  pieces 
of  wood,  the  sound  limb.  &c,  with  handkerchiefs  or  other  soft  material.  In 
this  way  tin-  jolting  of  the  patienl  during  transport  will  be  less  likely  to 
further  damage.  Where  there  is  much  pain  and  shock  an  injection  of 
morphia  gr.  ]  should  be  given  before  moving  the  patient. 

Surgical  Treatment.  On  coming  into  the  surgeon's  hands  the  following 
are  the  main  point-  in  I  reatment  : 


REDUCTION   OF  FRACTURES  229 

(1)  Reduction  or  setting  of  the  fragments,  i.e.  correcting  the  deformity. 

(2)  Fixation  or  maintaining  the  position  of  reduction  by  splints,  by 
position  of  the  limb,  or  by  internal  splints,  i.e.  plates,  wires,  screws,  &c. 

(.*$)  Restoration  of  the  nutrition  and  function  of  the  part  by  massage  and 
movements. 

Reduction  and  fixation  may  be  achieved  by  operative  or  non-operative 
methods.     We  will  consider  the  latter  first. 

A.  Non-operative  Measures  of  Reduction  and  Fixation.  (I)  Re- 
daction, or  setting  of  a  fracture,  i.e.  restoring  the  bone  to  its  normal  form, 
can  be  done  in  two  ways  :   (a)  Immediate,  (b)  Gradual. 

(a)  Immediate  reduction  is  accomplished  by  pulling  on  the  lower  frag- 
ment while  the  upper  is  kept  fixed,  and  manipulating  the  broken  ends  to 
exclude  interposing  substances,  such  as  muscle  or  fascia,  till  accurate  appo- 
sition is  obtained. 

Relaxation  of  the  spasmodically  contracted  muscles  is  accomplished  by 
suitable  manoeuvres  described  under  special  fractures,  or  by  administering 
a  general  anaesthetic,  which  is  often  useful  and  indeed  essential  to  secure 
adequate  reduction.  In  a  good  many  cases  adequate  reduction  without  open 
operation  is  impossible  ;  on  the  other  hand,  there  is  fairly  often  no  appreciable 
displacement  and  no  need  for  reduction,  e.g.  subperiosteal  fractures  and 
some  cases  of  Colles's  fracture,  &c.  Green-stick  fractures  usually  need  to  be 
completely  broken  across  to  attain  satisfactory  reduction. 

After  reduction  the  measurements  of  the  damaged  limb  should  be  com- 
pared with  those  of  the  sound  side,  and  after  fixation  a  radiogram  should  be 
taken  in  two  planes. 

(b)  Gradual  reduction  is  performed  by  the  use  of  weight-extension. 
Gradual  traction  thus  exercised  in  the  long  axis  of  the  limb  tires  out  the 
spasmodically  contracted  muscles  and  allows  the  overlapping  ends  to  come 
into  apposition,  and  the  maintenance  of  extension  acts  later  as  a  means  of 
fixation.  This  method  is  only  suitable  in  certain  situations,  such  as  shaft 
of  the  femur,  where  weight-extension  with  the  patient  in  a  recumbent 
position  often  gives  good  results,  also  in  fractures  of  the  upper  end  of  the 
humerus  ;  if  the  forearm  be  slung  at  the  wrist  there  is  considerable  traction 
exercised  on  the  upper  part  of  the  humerus  by  the  pendent  arm  and  forearm. 
while  the  patient  sits  or  stands.  Further  details  will  be  given  under  Special 
Fractures. 

(2)  Fixation  of  fractures  or  the  maintenance  of  apposition.  The  former 
is  an  unfortunate  term,  conveying  as  it  does  the  impression  that  the  limb 
should  be  kept  in  a  state  of  rigid  immobility  for  considerable  periods,  whereas 
what  is  really  needed  is  to  prevent  the  ends  of  the  fragments  slipping  away 
from  each  other.  Slight  movement,  of  a  bending  nature,  between  the  ends 
does  not  seem  to  cause  any  harm  and  in  some  instances  is  even  beneficial, 
while  absolute  fixation  of  the  limb  will  cause  great  wasting  of  muscles  and 
adhesions  in  joints  and  tendon  sheaths,  taking  long  to  recover.  Apposition 
of  fragments  is  maintained  in  various  ways  as  : 

(a)  By  arranging  the  limb  in  a  suitable  position. 


\  TEXTBOOK  OF  SURGERY 

(b)  The  use  of  splints  or  plaster  casts,  &c,  i.e.  external  apparatus. 

(c)  [ntenial  splints  such  as  screws,  plates,  etc.,  which  are  discussed  under 
the  Operative  Treatment  of  Fractures. 

{<!)  By  the  maintenance  of  extrusion,  which  has  been  already  employed  to 
cans."  reduction,  needs  no  further  description  here. 

(a)  Maintenance  of  the  position  of  fragments  by  position  of  the  limb  is 
instanced  by  the  placing  of  the  elbow  in  acute  flexion,  in  separations  of 
the  lower  epiphysis  of  the  humerus,  or  the  knee  in  a  similar  position  when 
the  lower  epiphysis  of  the  femur  has  been  detached. 

(b)  Externa.1  fixation  apparatus  is  made  of  all  manner  of  materials,  in- 
cluding wood,  leather,  iron.  zinc,  poroplastic.  gutta-percha,  plaster  <>l 
Paris,  water-glass,  gum  and  chalk.  &c,  and  such  apparatus  may  be  divided 
into  : 

(1)  Ready-made  splints  kept  in  suitable  sizes  to  suit  various  patients  and 
fractures. 

(2)  Splints  made  from  plastic  material  which  can  be  moulded  for  each 
as  it  occurs. 

( 1 )  In  this  group  are  included  those  forms  of  apparatus  made  in  definite 
sizes  of  wood,  iron,  &c.,  and  are  usually  long  flat  boards,  sometimes  joined 
together  to  the  number  of  two  or  more  at  appropriate  angles.  Such  splints 
must  be  well  padded  with  tow  to  prevent  pressure  on  bony  points,  and  the 
straps  or  bandages  maintaining  the  splints  in  position  should  not  be  so  tight 
as  to  interfere  with  the  blood-supply  of  the  limbs  ;  these  are  further  con- 
sidered under  Special  Fractures. 

(2)  To  make  apparatus  to  fit  individual  patients  the  most  useful  materials 
are  plaster  of  Paris,  gum  and  chalk,  or  poroplastic.  Leather  and  celluloid  are 
also  useful,  the  latter  being  very  strong  and  light,  but  these  take  a  long  time 
to  set  and  have  to  be  moulded  on  a  cast  in  plaster  previously  taken  of  the 
part,  and  are  therefore  more  suitable  for  professed  instrument- makers  than 
practical  surgeons,  unless  these  devote  most  of  their  time  to  this  branch. 
Plaster  of  Paris  is  applied  in  bandages  or  on  flannel ;  it  is  most  important 
that  plaster  before  use  should  be  thoroughly  dried.  Plaster  of  Paris 
bandages  are  made  by  robbing  recently-baked  plaster  into  coarse-meshed 
muslin  bandages.  Before  applying  a  plaster  case  the  part  should  be 
enveloped  in  a  flannel  bandage  thickly  applied,  and  it  is  wise  to  place  extra 
pads  of  wool  over  bony  prominences  such  as  the  malleoli,  &c. 

'I  he  plaster  bandages  are  soaked  in  water  for  about  twenty  seconds  till 
saturated,  and  applied  evenly  and  firmly  :  dry  plaster  and  water  are  rubbed 
in  between  each  pair  of  bandages  till  the  case  is  of  sufficient  thickness.  The 
plaster  should  set  in  about  five  minutes;  consequently  bandages  must  only  be 
-naked  just  before  they  are  needed,  or  they  will  set  before  being  applied. 
After  the  plaster  case  has  set  it  may  be  cut  through  with  a  sharp  knife  at 
the  front  and  back  so  that  it  is  in  two  halves  and  forms  a  removable  case. 
The  plaster  is  dried  slowly  for  twenty-four  hours,  the  edges  strapped  and 
the  case  is  finished.  If  plaster  sets  too  slowly  a  little  salt  added  to  the 
water  makes  the  process  rapid.     Such  plaster  cases  should   never  be  left 


SPLINTS  231 

fixed  immovably  on  fractures,  especially  of  recent  date,  for  the  swelling 
about  the  fracture  may  cause  interference  with  the  blood-supply  in  recent 
cases,  and  gangrene  or  ischseniic  contracture  result ;  while  even  if  this  is 
unlikely,  as  in  later  cases,  complete  immobilizing  of  the  limb  is  inadmissible  ; 
since  this  leads  to  so  much  wasting  and  stiffness.  Plasters  should  always  be 
removed  daily  and  massage  employed,  with  movements  of  the  smaller  joints. 
As  a  rule  a  plaster  case  is  applied  to  a  fracture  after  it  has  been  on  splint  for 
seven  to  twenty-one  days  and  should  be  always  removable  to  allow  of 
massage. 

The  application  of  plaster  on  Bavarian  flannel  is  a  useful  plan  of  making 
a  removable  plaster  case  (Croft).  For  this  method  strips  of  flannel  and  a 
mixture  of  plaster  in  water  of  the  thickness  of  thin  gruel  are  needed.  The 
limb  is  enveloped  as  before  in  a  flannel  bandage,  the  strips  of  flannel  are 
moistened  in  water,  saturated  with  the  thin  plaster,  applied  at  the  front  and 
back  of  the  limb,  leaving  a  narrow  space  at  the  side.  Two  thickness 
flannel  at  least  are  used  to  make  the  plaster  strong  enough,  and  are  bandaged 
on  quickly  with  cotton  bandages  as  soon  as  the  plaster  is  set.  The  case  can 
be  removed  by  cutting  down  the  sides  where  there  is  no  plaster  :  the  case 
is  finished  off  as  before. 

Another  plan  is  to  cut  out  pieces  of  flannel  to  form  lateral  splints  for  the 
limb  (usually  the  leg)  ;  these  are  soaked  in  the  plaster  gruel  and  placed 
between  two  pieces  of  lint  of  similar  shape  but  slightly  large  size  to  form  a 
sandwich,  and  each  of  these  sandwiches  is  bandaged  on  either  side  of  the  part 
affected,  first  one  and  then  the  other,  as  fast  as  possible,  before  the  plaster 
sets.  After  setting,  the  bandages  have  simply  to  be  removed  and  there  are 
left  well-fitting  plaster  casts  or  half-splints,  one  for  each  side. 

Poroplastic  is  a  useful  form  of  splint  material  for  many  fractures  and  is 
used  as  follows.  A  paper  pattern  is  cut  to  fit  the  part  and  a  piece  of  poro- 
plastic is  cut  to  fit  the  pattern  :  this  is  softened  in  hot  water  and  bandaged 
on  to  the  limb  in  the  required  position.  It  sets  rapidly  on  cooling,  becoming 
stiff  again. 

To  obtain  the  best  results  with  external  splints  and  such-like  apparatus, 
these  should  be  removed  if  possible  every  twenty-four  hours,  the  parts 
massaged  and  the  joints  moved  ;  this  is  possible  in  a  large  number  of  i 
without  causing  displacement  of  the  fragments.  If  removal  of  splints  readily 
causes  disturbance  of  the  fragments,  the  question  must  be  faced  whether  it 
is  better  to  persist  with  fixed  splints  and  no  massage,  or  whether  it  will  be 
wiser  to  turn  to  operative  methods  to  secure  fixation  of  the  fragments.  In 
general  it  may  be  stated  that  children  and  young  people  stand  prolonged 
fixation  in  splints  with  much  less  injury  to  muscles,  tendons,  and  joints,  than 
do  those  of  riper  years. 

B.  The   Operative  Treatment  of  Simple   Fractures.    This   is 
valuable  method   of  treating  certain   fractures,   but  has  two   important 
disadvantages  :   first,  that  in  exposing  a  fracture  to  perform  reduction  and 
fixation  of  the  fragments,  the  surroundings  must  suffer  additional  injury 
from  the  operation  itself,  while,  as  in  all   open  oper.it ions,  there  is  some 


\  TEXTBOOK  OF  SURGERY 

risk  of  tin-  aseptic  technique  failing,  and  the  results  of  such  failures  are 
especially  baneful  in  fractures.  Therefore,  if  operations  on  fractures  are 
to  be  performed,  they  should  be  left  to  those  \*  ho  are  in  the  ha  Kit  of  conducting 

operations  on  a  large  scale  and  whose  aseptic  reflexes  are  better  developed 
than  in  those  who  only  operate  occasionally. 

Indications  fob  Operative  Treatment.  In  general  this  is  needed 
where  adequate  replacement  of  the  fragments  is  not  possible  by  other 
methods,  unless  contra-indicated  by  the  age  or  diseased  condition  of  the 
patient.  In  some  fractures  it  is  clear  at  once  that,  short  of  operation,  there 
is  no  chance  of  any  sort  of  setting  of  the  fragments,  e.g.  when  the  fracture 
is  badly  comminuted.  What  we  mean  by  adequate  reposition  of  fragments 
varies  with  the  position  of  a  fracture  and  with  the  age  of  the  patient. 

(1)  Fractures  of  the  shafts  of  long  bones  do  not  need  to  be  in  such 
mathematically  perfect  apposition  as  do  the  fragments  when  a  fracture 
involves  a  joint.  A  fault  of  one  half-inch  is  less  important  in  the  shaft 
than  one-sixteenth  of  an  inch  when  a  joint  is  involved,  as  the  grating  of 
the  rough  surface  in  the  latter  case  will  erode  the  opposing  articular  carti- 
lage, and  set  up  osteo-arthritic  changes  in  the  joint. 

(2)  Where  short  bones  or  processes  of  long  bones  are  broken  across  and 
there  is  much  separation  of  the  fragments  from  muscular  traction,  operation 
is  generally  needed  to  give  a  strong  limb  and  rapid  convalescence  :  fractures 
of  the  patella  and  of  the  olecranon  are  good  examples  of  this  type  of  fracture. 

(3)  Absolute  accuracy  of  apposition  is  of  more  importance  in  the  lower 
than  the  upper  limb  because  of  the  limping  caused  in  the  latter,  and  possible 
secondary  changes  in  the  joints  (from  alterations  in  pressure  on  their 
surfaces,  due  to  changes  in  the  direction  of  the  axis  of  the  limb,  i.e.  angular 
deformity).  An  inch  of  shortening,  or  some  bending  in  the  humerus  will 
not  greatly  impair  the  use  of  the  arm,  but  in  adults  the  shortening  of  a  leg 
by  an  inch  makes  life  a  good  deal  more  arduous.  Children  accommodate 
themselves  to  such  deformity  much  more  readily,  and  in  them  shortening 
of  a  leg  by  one  inch  often  causes  no  appreciable  limping. 

(4)  The  direction  of  the  fracture  is  of  importance  ;  thus,  oblique  frac- 
tures,  being  much  harder  to  keep  in  good  position,  will  more  often  require 
operation  than  the  transverse  type. 

(5)  Where  cross-union  is  likely  to  occur,  as  in  fractures  of  both  the 
iad ins  and  ulna  in  the  middle  of  the  forearm,  operative  treatment  is  some- 
times the  only  resource. 

{('))  In  complicated  fractures  such  as  compound  fractures,  complications 
with  dislocations,  injuries  to  nerves  or  vessels,  in  delayed  or  non-union  or 
vicious  union,  operative  treatment  will  be  frequently  indicated;  these 
conditions  are  considered  in  a  later  section. 

(6)  Separated  epiphyses,  if  not  perfectly  reduced  by  manipulation, 
always  need  operative  treatment,  to  prevent  the  deformity  which  will 
resuh  from  growth  when  they  are  displaced. 

The  Time  at  wjuch  to  Operate.  Some  surgeons  advocate  waiting  a 
week  or  more  before  operating  on  fractures  under  the  idea  that  the  "  inflam- 


OPERATIVE  TREATMENT  OF  FRACTURES  233 

niation  "  will  then  pass  oft'.  This  is  hardly  in  accordance  with  the  teaching 
of  modem  pathology.  Waiting  only  means  that  the  extravasation  begins 
to  organize  and  callus  forms,  while  the  muscles  become  more  firmly  con- 
tracted and  shortened  :   there  is  in  simple  fractures  no  inflammation  of  the 


Fig.  73.     Methods  of  reducing  fractures  at  operation. 
I,  Traction.     II,  Pressure  on  the  extended  and  opposed  ends  of  the  fragments. 

infective  type,  which  might  cause  one  to  pause  before  operating,  but  onlv 
the  inflammation  of  repair.  Waiting  only  renders  operation  more  difficult, 
and  difficulty  in  these  operations  is  likely  to  interfere  with  the  successful 
issue.     Operation  for  fracture  is  indicated  in  three  classes  of  case. 

(1)  As  an  emergency  operation,  at  once,  if  there  is  some  associated  lesion 
of  a  large  vessel,  nerve,  viscus,  &c,  and,  of  course,  in  compound  fractures 
{see  later). 

(2)  Operation  is  advisable  within  three  days  where  it  is  inevitable,  as 


\  TEXTBOOK  OF  SI  RGER1 


in  fractures  ..I   the  patella,  or  into  other  joints,    in   badly  comminuted 
fractures,  &c. 

I     cages  where  the  propriety  of  operation  is  uncertain,  a  trial  of 

manipulation,  splints,  extension,  &c.,  may  be  made,  but  if  not  satisfactory 

within  a  week  recourse  should  he  had  t<>  operative  measures.     By  acting 

on  these  lines  mosl  cases  of  non-union  and  vicious  union  may  be  prevented. 

Obstacles  ro  Reduction  of  Fragments  bv  Non-operative  Means. 

( 1  )   .Muscular  spasm  may  act  by  : 

(a)  Pulling  the  fragments  apart     as  m  fractures  of  short  hones  such 

as  the  patella,  or  processes  of  larger  hone.-.,  as  the.  olecranon. 

(6)  By  causing  overlapping  of  the  fragments  in  the  shnlt  ol  a  long  bone 

and  pulling  the  ends  of  the  hone  together,  as  in  fractures  of  the  femur. 

tibia,  &c. 

{<■)  Angular  deformity,  as  in  the  upper 

third  of  the  femur  ;    and 

(d)  Rotary  deformity  (as  in  the  radius 

above  the  insertion  of  the  pronator  radii 

teres)  may  also  result  from  muscular  spasm. 

(2)    The    intervention    of    muscles    or 

fascia,  e.g.  in  fractures  of  the  patella  or 

entangling  of  the  ends  of  the  fragments 

in  these  structures,  as  in  fractures  in  the 

middle  of  the  femur  or  humerus,  will  also 

under   reduction   without  operative  help 

impossible  :  the  catching  of  the   end   of 

Era.  74    Levering  a  detached  epiphysis  the    diaphysis   through   a    "sleeve"    of 

into  position.     Note  the  untorn  peri-   periosteum,  in  cases  of  separation  of  epi- 
1  •'  sleeve.  . 

physes,  is  of  this  nature. 

.M  kthods  of  Operative  Treatment.  It  is  well  to  have  several  methods 
available,  since  it  will  often  be  found  that  one  of  these  is  pre-eminently 
suitable  in  any  given  case. 

In  the  first  place  the  most   rigid  asepsis  is  i <\vd.  and  is  even  more 

important  than  when  opening  the  abdomen,  since  the  hones  and  muscles 
are  tar  less  resisting  to  pathogenic  organisms  than  is  the  peritoneum.  The 
skin  may  be  prepared  in  the  usual  manner  with  iodine,  but  special  care 
is  needed  not  to  tear  the  rubber  gloves  on  sharp  fragments  of  bone  and 
introduce  an  element  of  uncertainty  as  regards  asepsis:  if  possible, 
the  fragments  should  not  be  handled  at  all.  hut  only  touched  with  instru- 
ments.    Besides  asepsis  the  technique  consists  of  reduction  and  fixation. 

Reduction  and  Fixation-.  Reduction.  'I  be  incision  over  the  fracture 
must  be  sufficiently  large  to  give  a  free  exposure,  and  in  most  instances  the 
ends  should  be  brought  out  of  the  wound,  previously  treeing  them  from 
entangled  muscles.  Sec,  with  a  rugine.  Where  the  fracture  is  transverse, 
it  the  ends  be  broughl  out  of  the  wound,  and  placed  together,  they  form  an 
angle,  and  it  this  angle  be  pushed  back  again  great  leverage  will  be  obtained 
to  extend   the  contracted    muscles  (Fig.  7:1.  II).     Where  the  fracture  is 


WTRIXG  FR  ACT  THE* 


23-") 


oblique,  traction  must  be  made  by  assistants,  or  clamps  must  be  fixed  to 
the  fragments,  and  separated  by  some  form  of  turn-buckle  ;  or  levers  may 
be  inserted  between  the  ends — this  is  useful  for  reducing  the  separation  of 
an  epiphysis.  Having  satisfactorily  reduced  the  fragments,  which  may  be 
very  difficult,  it  now  remains  to  fix  them  in  position.       (Figs.  73  I.  ~i.) 

Fixation.  (1)  Simple  reposition  of  fragments  is  suitable  for  some 
transverse  fractures,  especially  separations  of  epiphyses,  since,  once  reduced, 
in  many  instances  these  have 
little  tendency  to  become 
again  displaced  ;  or  this  can 
be  avoided  with  certainty 
by  a  suitable  position  of  the 
part  as  acute  flexion  of  the 
elbow  for  separations  of  the 
lower  epiphyses  of  the  hu- 
merus. 

(2)  The  wire  is  the  classic 
implement  to  unite  fractures, 
and  still  at  times  saves  the 
situation  when  the  more  mo- 
dern plate  and  screws  land 
the  surgeon  in  difficulties. 
Wiring  is  excellent  for  short 
bones  or  for  securing  short 
processes  of  long  bones,  when 
it  is  passed  through  holes 
bored  in  the  latt?r.  For 
long  bones  the  method  of 
drilling  holes  is  less  useful, 
for  it  is  difficult  to  maintain 
really  good  apposition  in 
this  manner. 

Two  or  more  wires  passed 
right  round  the  bone,  as  in 
splicing  a  fishing-rod,  afford  firm  and  satisfactory  apposition  of  oblique  and 
spiral  fracture  in  long  bones,  and  can  be  applied  where  plates  are  difficult,  as 
in  comminuted  fracture.  It  is  said  that  such  circumferential  wiring  predis- 
poses  later  to  fractures  at  the  seat  of  wiring,  but  we  have  not  found  this 
to  be  the  case  and  have  had  excellent  results  in  this  class  of  fracture.  How- 
ever a  wire  is  applied,  care  must  be  taken  not  to  overtwist  it  in  tightening, 
or  it  will  readily  break  off  ;  also  care  is  needed  not  to  twist  one  end  round  the 
other,  but  the  two  ends  of  the  wire  mutually  round  each  other  :  the  circum- 
ferential wire  may  be  used  to  reinforce  a  plate  in  difficult  cases  (Fig.  75). 

(3)  Ferrules  of  flexible  metal  such  as  aluminium  may  be  placed  round 
weak,  soft  bones  where  wires  or  screws  cut  out. 

(4)  Screws,  nails,  and  pegs.     Screws  alone  are  useful,  in  fractures  of 


Fig. 

in    a 


75.       Method   of    securing   fragments  of    bone 
comminuted    fracture    of   the  femvir  (from    a 
skiagram). 


236 


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cancellous  bone,  e.g.  in  fixing  on  a  separated  condyle  of  the  femur,  or 
the  olecranon,  and  for  these  operations  tin'  screws  must  be  adequately  long 
and  like  the  common  carpenter's  screw  used  for  wood,  i.e.  with  a  wide 


—-Iff 


Fro.  Tfi.     a.  Ferrule  of  flexible  metal. 
6,  Fracture  secured  by  a  ferrule. 


Fig.  77.     Carpenter's  screw  suit- 
able for  cancellous  bone  ;   metal- 
worker's screw  for  dense  bone. 


thread,  which  grasps  the  soft  bone  well.  Nails  and  tacks  are  occasionally 
useful  for  fixing  small  fragments  of  bone.  Long  steel  spikes  may  be  used 
where  there  is  difficulty  with  a  plate  or  wire;  thus  in  fracture  high  up 
the  humerus  a  spike  may  be  driven  right  through  the  head  and  upper 


Fig.  78.     Fractured  femur  ; 


<1  by  a  plate.     (Ski: 


fragment  into  the  lower  Eragmeni  oi  course,  penetrating  tie-  joint:  tins 
is  removed  in  two  to  three  weeks.  Ivory  pegs  may  be  used  and  h-U  embedded 
in  the  bone. 

(5)  Plates,  the  improvements  and  popularization  of  which  we  owe  largely 
to  the  work  of  Lane,  should  be  of  steel,  strong  but  flexible  enough  to  allow 
oi  then-  being  bent  with  strong  pliers  to  fit  snugly  the  possibly  curved 
surface  oi  bones.  They  are  fixed  with  screws,  which  need  not  be  more 
than  three-quarters  of  an  inch  long,  and  must  have  a  fine  thread,  rather 


PLATING  FRACTURES 


237 


coarser  than  screws  used  by  engineers  in  metal-work,  i.e.  of  much  finer 
thread  than  the  ordinary  carpenter's  screw,  otherwise  they  will  not  secure 
enough  grip  on  the  shaft  of  a  long  bone,  which  is  never  more  than  one-quarter 
of  an  inch  thick  ;  and  it  is  well  to  have  these  screws  filed  obliquely  at  the 
end  to  cut  into  the  bone  securely,  and  a  good  deal  of  help  is  gained  in  difficult 
places  by  the  use  of  a  screw-driver  which  grips  the  screw  during  the  first 
part  of  introduction.  Care  is  needed  that  the 
drill  to  make  the  screw-holes  in  the  bone  is 
just  smaller  than  the  calibre  of  the  screw. 
Where  screws  are  not  biting  well  it  may  be 
necessary  to  reinforce  with  circumferential 
wires.  An  ingenious  form  of  plate  has  been 
introduced  by  Souttar  which  has  the  proper- 
ties of  a  girder,  consisting  of  two  plates  joined 
at  light  angles  along  one  of  their  long  edges  : 
after  reducing  the  fracture  a  slot  is  cut  along 
the  bone  with  a  circular-saw  and  the  girder- 
plate   dropped    into    position,   being  secured 

with  a  few  screws  through  the  outside  plate,  Fig.  79.  Showing  the  use  of  atrisa- 
,....„  ii  •  i-      date  plate  for  comminuted  fracture, 

which   lies  flat  on  the  bone  ;    owing  to  this 

girder-form,  these  plates  give  great  rigidity  but  are  not  easy  to  introduce 

in  deeply  placed  fractures. 

(6)  Intramedullary  pegs  which  fit  the  medullary  cavity  of  each  fragment 
tightly  are  advocated  by  some  ;  we  have  not  found  occasion  for  their  use 
at  present. 

(7)  A  combination  of  internal  and  external  splinting  is  sometimes 
employed.  Four  screws  or  gimlets  are  screwed,  two  into  each  fragment, 
through  small  incisions  in  the  skin  ;  the  fragments  are  adjusted  by  traction 
on  these  screws,  and  the  outer  ends  of  the  screws,  which  stand  two  or  three 
inches  out  of  the  skin,  are  fixed  together  with  an  iron  rod  either  by  an 
arrangement  of  clamps  or  by  enveloping  the  rod  and  the  outer  part  of  the 
screws  in  plaster  bandages,  which  soon  set  and  render  the  whole  secure. 
We  have  seen  good  results  by  such  methods,  but  the  presence  of  screws 
passing  through  the  skin  for  several  weeks  must  tend  to  produce  infections 
in  some  cases  in  spite  of  all  care  ;  so  that  the  method  does  not  seem  likely 
to  replace  complete  internal  splinting  such  as  plating. 

(8)  Xail  extension  (Steinmann)  is  mentioned  under  Fractures  of  the  Femur. 

After-treatment  of  Fractures  by  Massage,  Movements  and  Exer- 
cises. This  part  of  treatment  is  hardly  less  important  than  the  restoration 
of  its  pristine  form  to  the  fractured  bone,  and  in  many  instances  even 
more  so.  Massage  is  a  most  important  adjunct  to  the  treatment  of  frac- 
tures ;    the  benefits  derived  from  its  use  are  : 

(1)  The  removal  of  coagulated  blood  and  lymph  from  around  the  seat 
of  fracture,  from  the  tendon-sheaths,  muscles,  tv.r. 

(2)  Stimulation  of  the  bones  and  periosteum  by  increasing  the  blood- 
supply,  and  so  promoting  more  rapid  union. 


\    rEXTBOOK  OF  SI  RGERY 

(3)  Keeping  up  the  vitality  and  tone  of  the  muscles  and  other  structures, 
Buch  as  the  nerves  and  skin,  and  bo  increasing  the  rapidity  with  which  the 
•ration  of  function  is  secured  in  the  damaged  limb. 

Massage  has  certain  limitations  or  contra-indications  : 

(a)  Massage  Bhould  not  I"'  commenced  for  two  to  three  days  after  the 
fracture  has  occurred,  or  the  increase  of  blood  to  the  part  may  cause  renewed 
haemorrhage  from  the  ruptured  vessels. 

(h)  Massage  is  unsuitable  it'  it  causes  disturbance  in  the  alignment  ol  the 
fragments  :  Blight  disturbance  does  no1  matter,  bu1  gross  disarrangement 
must  In'  strictly  avoided. 

(c)  Massage  is  far  more  important  in  adults  and  old  persons  than  in 
children,  since  the  greater  power  of  repair  in  young  subjects  renders  massage 
often  unnecessary. 

Varieties  of  Massage.  (I)  Effleurage,  or  stroking  in  a  rhythmical 
manner  from  the  periphery  to  the  centre  along  the  axis  of  a  limb,,  is  useful 
in  relieving  pain,  and  in  diminishing  muscular  spasm. 

Petrissage  or  kneading  with  varying  degrees  of  severity,  also  from 
periphery  to  centre,  is  most  useful  when  applied  to  soft  parts  such  as  muscles, 
where  it  promotes  increased  blood-supply  and  helps  to  remove  effusion. 

(3)  Tapottement,  including  the  movements  of  "  hacking "  with  the 
ulnar  border  of  the  hand  and  little  finger.  "'  clapping  "  with  the  palm  of 
the  hand,  &c,  are  useful  as  to  stimulate  muscles  and  nerves  and  more 
suitable  later  in  the  treatment  than  the  previous  methods. 

MOVEMENTS.  Passive  movements  should  be  used  early,  especially  in 
old  persons,  and  applied  to  small  joints  first,  e.g.  the  fingers  in  Colles's  frac- 
ture or  the  toes  in  Pott's  fracture.  With  care  considerable  amounts  of 
movement  can  be  performed  without  disturbing  the  fragments,  and  greatly 
improve  the  nutrition  of  the  part  and  prevent  adhesions  in  joints  and  tendon- 
sheaths.  Active  movements  are  most  important  of  all  in  restoring  function, 
but  tiny  must  be  used  with  greal  care  in  the  earlier  stages  to  prevent  their 
causing  deformity,  and  should  be  employed  so  as  to  give  a  good  range  of 
movement  without  straining  the  part .  Thus,  in  the  earlier  stages  of  recovery 
from  fractures  about  the  ankle  active  movements  may  lie  indulged  in,  but 
these  must  he  done  with  the  fool  off  the  ground  ;  on  no  account  must  the 
patient's  weighl  he  allowed  to  come  on  3uch  a  damaged  part  till  healing 
ha-  become  well  advanced. 

Complications  of  Fractures  \\i»  theib  Treatment.    These  may  he 

local  or  general,  and  in  the  Litter  instance  occur  al  the  time  of  injury  or 
during  the  course  of  treatment  :  the  following  conditions  may  lie  regarded 
.i~  complications  of  fracturi 

A.  Local  Complications.  (1)  Compound  fracture;  (2)  fractures  implica- 
ting joints  or  accompanied  by  dislocations:  (3)  fractures  associated  with 
injuries  to  vessels  or  (4)  nerves;  (5)  gangrene;  (*'>)  ischemic  contracture; 
(7)  non-union;    (8)  mal-union  ;   (9)  myositis  ossificans  ;   (10)  sarcoma. 

B.  General  Com/plications,  including  shock,  delirium,  fat-embolism, 
pneumonia,  bedsores,  crutch  palsy. 


COMPOUND  OB  OPEX  FRACTURES  239 

A.  Local  Complications.  (1)  A  com/pound  or  open  fracture  is  one  in 
which  there  is  a  breach  in  the  skin  or  mucous  membrane  leading  down  t<> 
the  fracture.  The  consequences  of  such  an  open  wound  leading  to  a  fracture 
may  be  most  serious,  the  main  dangers  being  :  (a)  Infection  of  the  bone 
and  its  surroundings  with  pathogenic  organisms,  introduced  through  the 
wound  and  leading  to  severe  spreading  osteitis,  periostitis,  cellulitis,  and 
possibly  pyaemia  or  septicaemia.  (6)  Haemorrhage,  which,  naturally,  is 
greater  if  the  blood  can  escape  through  an  external  wound  than  if  confined 
subcutaneously  ;  this  is  seldom  an  important  complication,  unless  it  be 
secondary,  (c)  Delayed  union,  which  is  due  partly  to  the  damage  to  the 
fragments  from  infection  and  inflammation,  partly  from  the  stripping  and 
injury  to  the  periosteum,  which  is  nearly  always  greater  in  an  open  than 
in  a  closed  fracture,  since  greater  violence  and  more  displacement  are 
needed  to  drive  the  fragments  through  the  skin  ;  and  such  protrusion  of 
the  fragments  usually  occurs  at  the  moment  of  fracture,  although  when 
seen  the  ends  may  have  slipped  back,  and  be  in  almost  normal  position. 

Repair  takes  place  as  in  simple  fractures,  if  the  wound  be  rendered  and 
maintained  aseptic,  but  is  of  slow  progress  as  a  rule  owing  to  the  greater 
damage  usually  present.  Should  infection  of  the  fragments  take  place 
healing  is  greatly  delayed,  since  some  necrosis  almost  certainly  results, 
and  the  sequestra  will  have  to  separate  before  union  can  take  place.  Six 
months  to  two  years  may  readily  elapse  before  soimd  healing  takes  place 
in  badly  infected  cases,  and  if  there  is  severe  local  or  general  spread  of  the 
infection,  it  may  be  necessary  to  amputate  the  limb  in  order  to  save  the 
patient's  life. 

Treatment  of  Compound  Fractures.  This  consists  essentially  in 
rendering  a  dirty  wound  aseptic,  and  requires  considerable  time  and  patience 
in  severe  cases.  Compound  fractures  vary  much  in  severity,  some  showing 
merely  a  small  puncture  leading  down  to  the  bone,  whilst  in  other  examples 
a  severe  lacerated  wound  is  foimd  with  undermined  edges,  pulped  tissues, 
and  much  fouling  with  dirt.  The  amount  of  cleansing  needed  depends  on 
the  extent  of  the  damage  to  bones  and  tissues. 

(a)  Where  there  is  a  small  puncture  leading  down  to  the  seat  of  fracture 
without  stripping  and  pulping  of  tissues,  it  will  suffice,  after  cleaning  the 
skin  with  iodine  solution  4  per  cent.,  to  swab  out  the  wound  with  this 
solution  or  with  spirit  and  biniodide  1  in  500  fir  1  in  20  carbolic  lotion, 
and  apply  a  sterile  dressing,  after  which  the  fracture  is  "  put  up  "  like  a 
simple  closed  fracture,  and  usually  will  heal  as  readily. 

(6)  Where  the  wound  present  is  more  severe  it  should  be  plugged  with 
gauze  soaked  in  iodine  solution,  biniodide  in  spirit,  or  turpentine,  while  the 
skin  is  shaved  and  made  aseptic  with  iodine  ;  then  the  wound  is  opened  up 
thoroughly  and  cleaned  with  iodine  solution  or  biniodide  in  spirit — all 
dead  skin,  pulped  muscles,  fouled  periosteum,  &c.  being  carefully  cut 
away,  as  well  as  any  completely  separated  pieces  oi  bone  :  bleeding-points 
should  be  secured  and  the  wound  washed  out  again  with  iodine  solution 
or  carbolic-acid  lotion  1  in  20.  or  biniodide  of  mercurv  in  water  1  in  2000. 


240  A  TEXTBOOK  OF  SURGERY 

and  then  closed,  with  drainage  for  two  days.  Some  advocate  swabbing 
out  a  badly  fouled  wound  with  pure  carbolic;  this  is  a  very  certain  anti- 
septic luit  causes  superficial  Bloughing  of  the  purified  tissues  and  delayed 
union  :  the  method  firsi  described,  it  carefully  carried  out,  will  be  just  as 
efficacious  and  Less  damaging  to  the  tissues.  Before  closing  the  wound  the 
Burgeon  should  determine  whether  the  fragments  can  be  retained  in  position 
by  splints,  extension,  or  position  of  the  limb,  and  if  this  seems  improbable 
the  fracture  should  be  united  with  plates,  screws,  wires,  &c.,  according 
as  seems  best.  If  possible,  such  foreign  bodies  should  not  be  included  in 
a  wound  of  doubtful  asepsis  ;  but  even  should  suppuration  take  place  after 
a  wiring  or  plating  operation,  there  is  no  reason  to  believe  that  the  insertion 
of  these  makes  the  condition  very  much  worse,  and  it  is  seldom  necessary 
t  i  remove  them  for  several  weeks,  in  which  time  there  will  be  enough  callus 
to  prevent  very  great  displacement  of  the  fragments  taking  place.  There- 
fore we  advocate  internal  splintage  (wires,  plates,  &c.)  whenever  the  frag- 
ments of  a  compound  fracture  tend  to  become  displaced  readily,  since  a 
great  deformity,  and  one  difficult  to  remedy,  may  result  from  compound 
fractures  where  the  fragments  are  allowed  to  become  displaced  :  while 
operating  careful  note  should  be  taken  of  injuries  to  nerves,  tendons,  &c, 
and  these  should  be  sutured  with  fine  chromic  catgut. 

Where  the  wound  is  more  severe  the  question  of  primary  amputation 
may  arise,  though  by  careful  aseptic  technique  this  confession  of  defeat 
can  usually  be  avoided.  Amputation  may  become  necessary  in  the  course 
of  an  infected  compound  fracture  when  the  infection  is  spreading  and 
cannot  be  controlled  by  incisions  and  drainage,  or  where  gangrene  super- 
venes or  where  the  infection  is  becoming  generalized  and  as  evidenced  by 
intermittent  fever,  rigors,  anaemia,  albuminuria,  wasting,  &c. 

Primary  amputation,  i.e.  with  no  attempt  to  save  the  limb,  is  necessary 
in  : 

(1 )  Complete  pulping  of  a  limb  or  the  part  of  it  affected. 

(2)  Where  there  is  such  stripping  of  skin  and  soft  parts  that  sloughing 
will  surely  be  widespread  and  the  ultimate  cicatrization  leave  a  useless 
limb  :  this  applies  chiefly  to  compound  fractures  of  the  foot  in  old  persons 
with  much  stripping  of  the  skin. 

('))  Where  the  main  artery  and  vein  have  become  occluded  by  laceration 
or  consecutive  thrombosis,  unless  the  surgeon  is  able  to  suture  the  vessels 
(the  eoiivct  treatment)  or  should  this  delicate  operation  not  prove  feasible. 

In  practically  all  other  conditions  of  compound  fracture  an  attempt 
should  be  made  to  save  the  limb,  since  one  can  seldom  be  certain  that 
recovery  is  impossible.  In  a  good  many  cases,  where  there  is  severe  pulping 
and  stripping  of  tissues,  it  will  be  clear  in  a  day  or  two  that  amputation  is 
needed  aftei  treatment  on  these  lines,  and  if  the  part  has  been  rendered 
approximately  aseptic  there  is  little  risk  of  amputation  in  this  stage.  The 
high  mortality  of  such  ^intermediate"  amputation  in  pre-antiseptic  days 
was  due  to  gross  infection  of  the  parts  amputated. 

(2)  Fractures  may  be  complicated  by  injuries  to  joints  in  twro  ways  : 


COMPLICATED  FRACTURES  241 

(a)  The  line  of  fracture  runs  into  a  joint.     (6)  The  fracture  is  close  to  a 
joint  which  is  dislocated  in  addition  to  the  fracture. 

(a)  In  this  case  there  may  be  a  large  fragment  of  bone  broken  off,  e.g. 
the  condyle  of  the  humerus  or  femur,  or,  associated  with  a  partial  dislocation 
or  severe  sprain,  small  fragments  of  bone,  to  which  one  of  the  ligaments  of 
the  joint  is  attached,  may  be  dragged  off.  These  "  sprain-fractures  "  are 
not  uncommon,  and  have  been  noted  frequently  of  late  years  since  the 
more  general  use  of  radiograms  in  the  investigation  of  fractures. 

The  results  of  fracture  into  the  interior  of  joints  are  :  (1)  Effusion  of 
blood  and  lymph  into  the  joint,  leading  to  adhesions  and  rigidity  of  the 
latter.  (2)  Deformity  of  the  smooth  cartilage-covered  articular  ends,  and 
subsequently,  owing  to  movements,  erosion  of  the  joint  surfaces  by  the 
rough  fragments,  and  the  onset  of  traumatic  osteo-arthritis.  (3)  The  pulling 
off  of  fragments  of  bone  in  sprain-fractures  may  lead  to  weakness  of  the 
joint  (being  equivalent  to  a  ruptured  ligament).  (4)  The  fragments,  being 
small,  are  uncontrollable  by  external  splinting  and  may  be  pulled  apart  by 
muscular  spasm,  e.g.  the  patella,  spine  of  the  tibia,  coronoid,  &c. 

Treatment.  Since  early  movement  is  necessary  to  prevent  the  formation 
of  clogging  adhesions,  and  accurate  alignment  of  the  broken  articular  surface 
is  essential  to  prevent  breach  of  contour  of  the  bearing  surfaces  of  the  joint, 
it  is  clear  that  open  operation  and  fixing  the  fragments  accurately  will  often 
be  needed  in  such  conditions. 

(b)  The  same  force  which  causes  a  fracture  may  produce  dislocation  of 
a  neighbouring  joint,  and  if  the  two  lesions  are  close  together  there  may  be 
considerable  difficulty  in  diagnosis,  e.g.  when  a  dislocation  of  the  upper  end 
of  the  humerus  complicates  a  fracture  of  the  neck  of  that  bone.  In  other 
instances  the  combination  forms  a  well-recognized  type  of  fracture  or 
fracture-dislocation,  as  in  fractures  of  the  lower  one-third  of  the  fibula 
associated  with  dislocation  outward  and  backward  of  the  ankle  (Pott's 
fracture). 

Treatment  is  directed  to  replacing  the  dislocated  fragment  back  into 
its  socket  and  reducing  the  fracture.  This  may  be  a  comparatively  simple 
matter  and  possible  by  external  manipulation,  as  in  many  instances  of 
Pott's  fracture,  or  may  be  hardly  possible  without  open  operation,  as  in 
fracture-dislocations  about  the  shoulder.  Failing  to  reduce  both  the 
fracture  and  dislocation  by  manipulation  and  extension,  open  operation 
should  be  undertaken  at  once  unless  the  patient  be  unfit,  from  age  or  debility, 
for  such  measures.  If  the  dislocated  fragment  be  the  entire  end  of  a  bone, 
no  pains  should  be  spared  to  replace  it  in  its  proper  socket ;  small  fragments, 
as  found  in  sprain-fractures,  will  generally  need  removal. 

(3)  Injury  to  the  Main  Vessels  may  be  laceration  with  extravasation  of 
blood,  or  bruising  followed  by  thrombosis  and  blocking  of  the  vessels ; 
either  the  artery  or  vein  may  be  injured  alone,  or  both  may  suffer ;  the 
great  danger  of  such  complications  is  the  production  of  gangrene  from 
interference  with  the  blood-supply. 

Obstruction  of  the  artery  alone  by  thrombosis,  following  on  bruising, 
i  16 


l'Il'  \    rEXTBOOK  OF  SURGERY 

will  be  detected  1>\  cessation  of  the  pulse  in  the  limb  In-low  the  obstruction 
and  pallor  of  the  part;  in  mosl  instances  the  anastomotic  circulation 
becomes  re-established  and  no  great  harm  results,  but  sometimes  gangrene 

of  the  peripheral  parts,  especially  of  toes,  results.  Should  the  main  artery 
be  ruptured  a  large  extravasation  of  blood  is  likely  to  occur,  which  rapidly 
increases  in  size  and.  pressing  on  the  vein,  interferes  with  the  blood-supply 
ich  a  degree  that  moist  gangrene  is  very  likely  to  supervene  unless 
clotting  takes  place  in  the  vessel  In-fore  the  extravasation  is  very  large. 
Blocking  of  the  main  vein  by  clotting  leads  to  oedema  of  the  limb,  which 
may  lead  to  delayed  restoration  oi  function,  hut  is  unlikely  to  result  in  more 

ius  complications.  Occlusion  of  the  artery  and  vein  together  is  very 
apt  to  lead  to  gangrene.  Should  the  fracture  he  compound,  enough  blood 
may  l>e  lost  from  the  ruptured  vessel  to  produce  collapse  and  even  endanger 
life,  hut  as  a  rule  loss  of  blood  Erom  compound  fractures  is  but  slight. 

Treatment.    The   probabilities  of  gangrene  arising  must   be  carefully 

sidered  Where  the  fracture  is  compound  the  extent  of  damage  to 
sis  can  he  determined  when  the  fracture  is  explored. 

In  simple  fractures  the  utmost  care  should  be  taken  to  maintain  the 
warmth  of  the  limb  till  circulation  is  restored,  and  avoid  impeding  the 
already  enfeebled  circulation  by  tight  bandaging.  The  following  are 
indications  for  immediate  exploration  of  the  vessels. 

(a)  A  large,  rapidly  increasing  hsematoma  caused  by  rupture  of  the 
main  artery. 

0>)  Failure  of  the  circulation  to  recover  within  an  hour  of  reduction  of 
tin-  fracture,  the  limb  remaining  pale  and  pulseless  or  dark  and  osdematous. 

'I  In-  injured  vessel  should  be  dealt  with  according  to  the  technique 
described  in  the  section  on  blood-vessels,  i.e.  a  ruptured  artery  should  be 
BUtured  if  possible  or  tied  at  each  end  :  if  both  vessels  are  divided  it  is 
tial  to  restore  the  continuity  of  one  of  them  by  suture  or  grafting  a 
portion  of  saphenous  vein  into  the  gap.  where  a  considerable  length  is  hors 
if,  combat. 

(1)  Nerves  may  be  injured  at  tin-  time  of  fracture  by  sharp  fragments 
of  the  broken  bone,  or  later,  by  growth  of  callus  or  injudicious  treatment, 
such  as  splinting  or  bandaging  too  tightly,  or  catching  the  nerve  between 
the  .-nds  of  the  fragments  while  reducing  the  fracture,  as  sometimes  happens 
to  the  musculo-spiral  nerve  in  fractures  of  the  shaft  of  the  humerus.  In 
such  injuries  of  nerves  division  is  rarely  complete,  and  as  a  rule  recovery 
will  follow.  Seeing,  however,  thai  complete  division  of  a  nerve  recovers 
much  mop-  rapidly  and  completely  if  diagnosed  and  treated  at  once,  it  is 
clear  that  nerve  injuries  associated  with  fractures  should  be  noted  before 

tmenl  Is  commenced,  as  in  no  other  manner  can  one  be  sure  that  the 
tused  by  the  fracture  and  not  by  the  growth  of  callus  or  pressure 
ilints. 

ft    is  wise  in  all  cases  of    fractures,    as   in    other  injuries,   quickly  but 

ematically  to  examine  the  pari  of  the  limb  below  the  injury  for  changes 
:  "ii.  both  epicritic  (light  touch)  and  protopathic  (pin-prick),  and 


NON-UNION,  ETC.  243 

test  the  voluntary  muscular  power  (see  Injuries  of  Nerves),  If  a  definite 
injury  is  discovered  it  will  be  best  to  explore  at  once,  since  it  may  be  incom- 
plete or  physiological,  but  if  left  may  become  complete  and  anatomical, 
and  only  by  operating  can  we  with  certainty  take  steps  to  prevent  the 
condition  becoming  worse,  e.g.  by  interposing  a  flap  fascia  between  a  projec- 
tion and  the  nerve  :  and  if  divided,  the  sooner  it  is  sutured  the  more  speedy 
and  complete  the  recovery,  while  if  nothing  has  to  be  done  there  is  little 
harm  in  an  aseptic  incision. 

(5)  Gangrene  complicating  fractures  has  already  been  discussed  when 
arising  from  pulping  of  the  limb,  or  rupture  of  the  main  vessels.  It  only 
remains  to  mention  the  possibility  of  gangrene  arising  from  over-tight 
bandages,  splints,  plaster-cases,  &c.  This  unfortunate  complication  of 
fractures  should  be  quite  avoidable  if  reasonable  care  be  used  in  the  appli- 
cation of  splints,  plasters,  &c,  always  taking  care  after  applying  such 
apparatus  to  leave  some  part,  such  as  the  toes,  visible  at  the  distal  limit  of 
the  apparatus  to  serve  as  a  sample  of  the  circulation,  and  if  there  is  blueness 
of  the  extremities  to  readjust  the  apparatus.  Pain  is  an  important  indica- 
tion of  too  great  pressure  when  complained  of  at  some  point  awav  from  the 
fracture,  such  as  the  heel,  and  any  such  painful  spot  should  be  investigated 
by  removing  the  splint.  It  is  important  to  note  that  the  initial  pain  passes 
off  in  a  few  hours  when  gangrene  has  developed  ;  hence  there  should  be  no 
delay  if  complaints  are  made,  nor  any  waiting  to  see  if  the  pain  becomes 
easier,  but  the  splints  readjusted  at  once  lest  the  surgeon  have  the  mortifi- 
cation, on  removing  the  bandages  some  days  later,  to  find  a  black  slough — 
by  this  time  often  painless — over  some  bony  projection,  which  will  surely 
lead  to  an  ulcer  taking  long  to  heal. 

Early  massage  by  relieving  the  part  of  the  constant  pressure  of  splints 
will  be  of  considerable  service  in  avoiding  such  unpleasant  sequelae. 

(6)  Ischcemic  Contracture  (Volkmann's  contraction)  is  liable  to  follow 
the  use  of  tight  bandages,  splints  and  plasters,  and  is  discussed  under 
Injuries  of  Muscles. 

(7)  Non-union  and  Disunion.  When  the  fragments  of  a  fracture  fail  to 
unite  various  conditions  are  found,  which  may  be  classed  under  three  heads  : 

(a)  Absolute  n<>),  -  an  ion,  where  no  attempt  at  repair  is  made,  is  uncommon  ; 
the  most  usual  examples  are  found  in  fractures  through  deposits  of  new 
growth  in  bone,  whether  sarcoma  or  secondary  cancer.  In  other  instances 
apparently  normal  bones  show  no  tendency  to  form  callus,  the  ends  gradually 
becoming  atrophic  and  pointed.  This  is  most  likely  to  take  place  in  old 
and  debilitated  subjects,  but  we  have  seen  a  case  of  this  nature  in  an 
apparently  healthy  lad. 

(b)  Fibrous  union,  where  the  ends  are  united  and  surrounded  by  fibrous 
tissue,  allowing  movement  ;  in  fact,  the  ends  are  surrounded  by  provisional 
callus  which  for  some  reason  is  unable  to  calcifv.     (Fig.  86.) 

(c)  Pseudarthrosis,  or  the  formation  of  a  false-joint,  is  a  rare  condition 
in  which  the  ends  of  the  fragments  are  covered  with  cartilage  and  the 
surrounding  connective  tissue  forms  a  capsule  to  the  false  joint. 


_'ll 


\  TEXTBOOK  OF  SURGERY 


The  conditions  leading  to  non-union  are  : 

(1)  Lack  of  apposition  of  the  fragments  due  to  : 

(a)  Separation  by  muscular  spasm,  e.g.  fracture  of  the  patella  or  ole- 
cranon. 

(b)  Intervention  of  some  foreign  substance  such  as  fascia,  muscle,  blood- 
clot..  &c.,  often  found  in  fractures  of  the  femoral  and  humeral  shafts  (this 

condition  is  the  basis  of  the  operation 
devised  by  .Murphy  for  forming  artificial 
joints  (arthroplasty)). 

(2)  Deficient  nutrition  of  the  bone  or 
periosteum  at  the  seat  of  fracture,  due  to  : 

(a)  General  failure  on  the  part  of  the 
patient  to  produce  callus,  the  cause  being 
unknown. 

(b)  Injury  to  the  arterial  supply  of  the 
part,  e.g.  intracapsular  fractures  of  the 
femoral  neck. 

(c)  Damage  to  the  periosteum  by  much 
stripping  of  the  latter  in  severe  comminuted 
fractures  ;  or  infection  of  the  periosteum, 
as  in  compound  fractures. 

(3)  Local  and  general  disease  of  the 
bone  :     (a)    Inflammatory,   as  a  gumma  ; 

(b)  new  growth,  as  secondary  cancer  ;    or 

(c)  general  dystrophy,  as  osteomalacia. 

(d)  General  diseases,  such  as  scurvy, 
alcoholism,  syphilis,  fevers. 

(5)  Want  of  rest  of  the  part  is  often 
stated  to  be  a  cause  of  non-union,  but 
unless  this  is  sufficient  to  produce  dis- 
placement of  the  fragments  so  that  appo- 
sition is  longer  present,  it  is  doubtful  if 
slight  movement  is  of  the  least  disadvan- 
tage. 

Treat  incut  of  non-union  varies  with  the 
cause  :  if  due  to  lack  of  ossifying  power  in 
the  callus  (delayed  union),  the  fragments 
being  in  good  position,  vigorous  massage 
should  be  applied,  strong  petrissage,  hacking,  clapping,  beating,  &c,  for 
Borne  weeks,  the  fracture  being  kept  in  good  position  by  means  of 
a  removable  plaster-case.  Passive  hyperaemia  with  Bier's  bandage  may 
be  tried,  but  the  effecl  is  usually  less  than  that  of  massage.  Where 
r_"'  fails  to  produce  the  desired  el'leet  after  several  weeks,  the  site 
of  fracture  should  be  explored  by  open  operation  if  the  patient's  general 
condition  admit  of  this  (the  fracture  should  be  examined  with  X-rays  to 
exclude  such  conditions  as  fracture  due  to  secondary  malignant  growth, 


V"  .    80.      Non-union  of  a  fractured 
radios   and  ulna  (child  set.  4)  da 
two    and    a   half  years.       Bone-graftS 

from   t  lii-  fibula   have  been  insei  ted, 
marked    by   the  arrow  on  each  side. 


NON-UNION 


245 


rendering  operation  out  of  the   question,   and   the   patient   examined  for 
general  disease,  which  might  also  render  operation  irrational). 

The  treatment  at  operation  will  depend  on  the  condition  found.     In 
cases  of  absolute  non-union  the  thin  pointed,  atrophic  ends  of  the  fragments 
should  be  removed  till  normal  firm  bone  is  encountered,  when  the  ends 
should  be  united  with  plate  or  wire,  &c,  as  seems  convenient.    Bone-graftino- 
may  be  employed  when  there  is  a 
breach  of  continuity  from  separa- 
tion of  sequestra  after  compound 
fractures,  &c.       Where   there  is 
fibrous  union  and  non-union  from 
failure    in   apposition,    the    ends 
should  be  disentangled  from  fas- 
cia, muscles,  &c,  freshened,  and 
brought  into  apposition  with  suit- 
able apparatus— wires,  plates,  &c. 
Tenotomies  or  partial  division  of 
muscles  may  be  needed  to  allow  of 
this,  and  in  old-standing  cases  the 
ends  may  need  to  be  denuded  of 
cartilage.     Non-union  from  such 
causes  should  be  uncommon  now, 
since  lack  of   apposition  of  the 
fragments  can  be  readily  detected 
by    taking    radiograms    in    two 
planes,    and    operating    early   if 
position    is    not    good.       Local 
disease   of   bone  will  be  treated 
by  scraping,  excision,  amputation 
or    splinting,    according   to    the 
condition   present.      Patients   in 
whom    operative    measures    are 
not  indicated  from  age  or  general 
condition  will  need  some  form  of  apparatus  to  stiffen  the  broken  part  of 
the  limb,  and  allow  of  its  use. 

General  disease,  such  as  scurvy,  syphilis,  &c,  will,  of  course,  need  specific 
treatment. 

Disunion  is  a  rare  condition,  and  implies  the  solution  of  union  of  a 
fracture  already  united  owing  to  some  constitutional  disease. 

(8)  Mal-union  or  vicious  union  :  by  this  term  is  meant  union  of  a  fracture 
with,  such  deformity  as  is  prejudicial  to  the  use  of  the  limb.     (Fig.  81.) 

In  most  instances  slight  deformity  does  not  impair  the  function  of  the 
limb  ;  in  fact,  a  considerable  amount  of  deformity  is  often  necessary  to 
cause  much  disability,  varying  with  the  position  of  the  fracture  and  t In- 
capacity of  the  patient  for  accommodating  himself  to  altered  circum- 
stances. 


Fig.  81.     Mal-union  of  fracture.     1,  Shortening 

of  the  femur.     2,  Angular  deformity  of  lower  end 
of  humerus,  causing  cubitus  varus. 


•_'i<;  \    I  EXTBOOK  OF  SURGERY 

Various  sorts  <>l  deformity  are  found  in  case  ol  vicious  union,  pist  as 
in  the  displacements  of  fragments  at  the  time  of  fracture. 

Thus  we  have  angular  and  rotary  deformity,  shortening,  and  cross- 
union. 

(a)  Angular  deformity  is  common  in  the  humerus  and  femur;  in  cither 
case  the  deformity  is  usually  a  bowing  outward  of  the  bone. 

(It)  Rotary  deformity  is  exemplified  by  fractures  of  the  femur  in  which 
the  lower  end  readily  becomes  everted,  carrying  the  foot  with  it.  resulting 
in  splay-footed  progression  and  flat-loot  disability.  This  type  of  deformity 
is  also  found  in  fractures  of  the  radius  above  the  insertion  of  the  pronator 
radii  teres,  and  results  in  loss  of  supination. 

(c)  Shortening  is  mostly  noted  in  the  femur  and  tibia,  and  is  of  far 
greater  importance  in  the  lower  than  in  the  upper  limb  on  account  of  the 
limping  which  results,  and  this  dot's  not  usually  occur  from  shortening  unless 
the  amount  is  more  than  one  half-inch. 


Fig.  82.     Cross-union  of  the  radius  and  ulna  following  fracture  of  both  hones. 

((/)  Cross-union  is  found  in  fracture  of  the  radius  and  ulna  together  in 
the  middle  of  the  forearm,  and  leads  to  loss  of  pronation  and  supination. 

Treatment.  Mal-union  should  not  be  allowed  to  occur  ;  careful  measure- 
ments and  skiagrams  will  detect  improper  position  and  manipulative  or 
operative  asures  are  taken  to  obviate  such  unfortunate  results. 

Should  union  have  occurred,  if  the  callus  is  soft,  angular  deformity  can 
lie  corrected  by  forcible  manipulation  and  refracturing  the  bone.  In  the 
other  varieties,  and  where  the  callus  is  firm,  such  measures  will  hardly  be 
successful,  and  open  operation  is  indicated  unless  the  condition  can  be 
obviated  by  some  simple  appliance,  such  as  a  thickness  of  cork  in  the  sole 
of  the  boot,  to  lengthen  the  lower  limb  where  there  is  shortening  of  the 
femur  or  tibia,  of  not  more  than  one  and  a  hall  inches.  Angular  and  rotary 
deformities  are  corrected  by  osteotomy  at  the  seat  of  fracture  ami  plating 
the  fragments  in  propel  position.  In  case  of  great  shortening  from  over- 
lapping, in  addition  to  division  of  the  bone,  the  contracted  muscles  and 
tendons  may  require  division  and  lengthening  as  well  ;  or  weight-extension 
may  he  applied  lor  a  lew  days  after  division  of  the  bone  to  ensure  adequate 
lengthening  before  the  ends  of  the  fragments  are  united.  Cross-union 
demands  division  of  one  or  both  bones,  removal  of  redundant  callus,  fixation 
of  the  fragments  with  wire  or  plate,  and,  if  possible,  the  intervention  of  a 
piece  of  fascia  between  the  bones  at  the  seat  of  fracture  to  prevent  recurrence 
of  the  cross-union. 

(!t)  Myositis  ossificans  of  the  local  variety  may  follow  on  fractures,  but 
as  this  condition  also  is  a  sequel  of  sprains  and  dislocations,  it  should  perhaps 


GENERAL  COMPLICATIONS  OF  FRACTURES  247 

be  regarded  rather  as  the  result  of  injury  to  the  muscles  and  tendons  which 
accompany  a  fracture  than  as  being  due  to  the  fracture  itself. 

(10)  Sarcoma.  It  is  questioned  by  many  as  to  whether  injury  ever 
gives  rise  to  sarcoma.  Coley  brings  forward  evidence  suggesting  that  in 
some  instances  such  origin  is  highly  probable.  In  most  cases  of  sarcoma 
associated  with  fracture,  however,  the  sarcoma  is  the  predisposing  cause 
and  not  the  result  of  such  fracture. 

(B)  General  Complications  of  Fractures.  We  have  already  drawn 
attention  to  the  occurrence  of  fever,  delirium,  shock,  and  fat  embolism, 
which  if  severe  must  be  regarded  as  complications  rather  than  as  normal, 
general  signs  of  fracture-:  there  remain  to  be  considered  pneumonia,  bed- 
and  splint-sores,  and  crutch-palsy. 

(1)  Pneumonia  of  the  hypostatic  variety  is  very  likely  to  occur  in  old 
persons  if  kept  long  on  their  backs,  and  this  position  is  to  be  avoided  in 
fractures  of  the  upper  end  of  the  femur,  which  are  common  in  such  patients. 
In  such  conditions  the  patient  should  be  got  out  of  bed  early  and  the  fracture 
kept  in  suitable  position  writh  Thomas's  splint  or  a  plaster-case  :  all  patients 
who  are  elderly, of  a  bronchitic  habit,  or  scant  of  breath  come  under  this  head. 

(2)  Bed-sores  must  be  carefully  guarded  against,  especially  in  old  persons. 
Under  the  heading  Gangrene  enough  has  already  been  said  about  splint-sores. 

(3)  Crutch-palsy,  from  pressure  of  the  head  of  the  crutch  on  the  brachia  i 
plexus,  is  not  unusual  after  fractures  of  the  lower  limb  if  the  ordinary  type 
of  crutch  be  used.  The  museulo-spiral  nerve  is  first  affected,  the  patient 
complaining  of  weakness  of  grip  and  dropped  wrist.  This  may  be  prevented 
by  well  padding  the  head  of  the  crutch  and  having  a  second  handle  about 
two  and  a  half  feet  down  the  crutch,  which  is  grasped  by  the  hand  and 
takes  a  good  deal  of  the  weight.  Should  signs  of  museulo-spiral  palsy  be 
noted,  the  use  of  the  crutch  must  be  discontinued,  the  forearm  massaged 
daily,  and  the  wrist  kept  in  a  position  of  hyper-extension  to  prevent  over- 
stretching of  the  extensor  muscles  from  the  dropped  position  of  the  wrist. 
{See  Injuries  of  the  Museulo-spiral  Neive.) 

INJURIES   OF  JOINTS 

These  consist  of  contusions  and  sprains,  wounds  and  dislocations. 

Contusions,  Sprains,  and  Strains  of  Joints.  These  are  the 
results  of  very  similar  causes  :  whether  the  synovial  .membrane  and 
ligaments  are  bruised  by  contusions  or  over-stretched  and  torn  by 
sprains  and  strains,  the  result  is  an  effusion  of  blood,  serum  and 
lymph  into  the  cavity  of  the  joints  and  into  the  substance  of  its  capsule. 
When  the  effusion  is  mostly  serous  the  condition  is  described  as  "  hydrops 
articuli  "  or,  more  popularly,  as  "  water  in  the  joint  "  in  question  ;  when 
the  effusion  is  mostly  of  blood,  as  noted  from  the  rapid  swelling  of  the 
joint,  the  term  "  hsemarthros  "  is  applied.  The  sequela?  sometimes  arising 
from  such  injuries  are  tuberculosis,  osteo-arthritis,  and  ankylosis  of  the 
joint.  Ruptured  ligaments  heal  slowly  and  tend  to  stretch  ;  hence  severe 
sprains  need  as  much  or  more  care  in  treatment  than  do  fractures. 


\  TEXTBOOK  OF  SURGERY 

-  gns.  Pain  and  swelling  <>f  the  part,  mapping  oui  the  synovial  pouches 
of  the  joint,  and  also  in  severe  cases  affecting  surrounding  tissues  (extravasa- 
tion oi  blood)  :  abnormal  mobility  owing  to  complete  tearing  of  ligaments, 
e.g.  lateral  movement   in  the  knee-joint  when  the  leg  is  extended,  after 

rupture  of  the  internal  lateral  ligament. 

Treatment.  In  the  early  stages  firm  pressure  with  a  bandage  moistened 
with  cold  water  or  evaporating  spirit  lotion  will  check  further  effusion. 
Alter  three  days,  massage  and  movements  both  active  and  passive  should 
be  commenced.  Where  a  joint  is  very  tense  and  painful  the  blood  may 
be  removed  by  aseptic  operation  and  the  joint  firmly  bandaged  over  wool. 
In  cases  where  there  is  no  great  injury  to  ligaments,  firm  strapping  combined 
with  graduated,  active  movements  commenced  on  the  third  day  is  good 
treatment  the  strapping  being  changed  as  soon  as  it  becomes  loose  from 
absorption  of  the  effusion.  Early  gentle,  passive  and  active  movements 
are  important  to  prevent  the  formation  of  adhesions,  and  of  these  active 
are  the  more  important  as  helping  to  maintain  the  tone  of  muscles  as  well, 
however,  is  needed  to  ensure  that  no  strain  comes  on  weakened  or 
ruptured  ligaments,  e.g.  the  weight  of  the  body  should  not  be  allowed  to 
strain  the  internal  lateral  ligament  of  the  ankle-joint  after  severely  sprained 
ankle  for  some  weeks  lest  permanent  lengthening  of  the  ligament,  with 
flat-foot,  result.  Where  there  is  complete  rupture  of  important  ligaments 
operative  treatment  is  advisable,  the  ligament  being  sutured  ;  and,  if 
necessary,  an  ambulatory  apparatus  should  be  worn  to  prevent  deformity 
resulting  where  the  damage  to  any  ligament  is  sufficiently  great  to  render 
this  complication 'likely.  Finally,  it  should  be  remembered  that  sprains 
often  complicate  fractures  (sprain-fractures),  and  the  sprain  is  sometimes  the 
more  important  part  :  while  in  other  instances  the  effect  of  a  small  portion 
of  bone  torn  off  inside  a  joint,  if  not  diagnosed  and  removed  by  operation, 
is  very  likely  to  lead  to  great  impairment  of  the  joint  in  the  near  future. 

Wounds  of  Joints.  Penetrating  wounds  of  joints  are  important  from 
the  risk  of  such  joints  becoming  infected  and  thus  leading  to  possible  destruc- 
tion and  ankylosis  of  the  joint,  or  diffuse  infection,  needing  wide  incisions 
or  even  amputation,  and  in  some  instances  ending  in  septicaemia  or  pyaemia, 
though  with  modern  aseptic  methods  these  latter  unfortunate  sequela;  are 
not  common.  The  synovial  membrane  of  joints  is  far  more  susceptible  to 
infection  than  is  the  peritoneum,  and  infections  in  such  situations  more 
nadily  become  generalized.  Small  punctured  wrounds  of  joints  may  fail  to 
sel  up  infection,  since  the  passage  of  such  an  object  as  a  needle  through  the 
lies  may  sweep  off  any  organisms  before  it  reaches  the  joint. 
Diagnosis.  Cases  of  small  punctured  wounds  in  the  vicinity  of  joints 
should  be  watched  with  care  for  the  first  few  days  for  signs  of  arthritis  to 
develop,  indicated  by  fever,  rapid,  painful  swelling  mapping  out  the  synovial 
cavity  of  the  joint.  Diagnosis  is  easy  when  the  wound  is  of  some  size  and 
the  interior  of  the  joint  can  be  seen  ;  where  the  wound  is  smaller  the  escape 
of  glairy,  synovial  fluid  will  show  the  nature  of  the  injury,  and  if  the  wound 
be  larger  than  a  needle-prick  it  will  usually  be  wise  to  enlarge  it  under 


DISLOCATIONS  249 

aseptic  precautions  and  see  if  it  penetrates  the  capsule.  Immediate  swelling 
of  the  joint  is  not  of  much  value  in  diagnosis,  as  it  may  be  due  to  associated 
traumatic  synovitis  from  a  non-penetrating  injury. 

Treatment  should  be  on  the  lines  indicated  for  compound  fractures. 

(1)  Where  a  small  puncture  is  present,  not  certainly  piercing  the  capsule, 
the  skin  should  be  sterilized  with  iodine  solution  and  covered  with  aseptic 
dressing,  the  limb  placed  on  a  splint  and  watched  for  two  or  three  days. 
Small  punctures  about  joints  should  never  be  probed,  as  this  conveys  no 
information  and  may  lead  to  pushing  septic  matter  further  in ;  where 
penetration  is  suspected  it  will  be  wiser  to  explore  along  the  track  of  the 
puncture  by  open  operation.  Should  such  a  joint  swell  up  after  some  hours, 
it  should  be  aspirated  aseptically  and  the  fluid  examined  for  pus  and 
organisms  ;  and  if  these  are  found  the  joint  should  be  opened,  washed  out 
with  antiseptic  lotion  such  as  iodine  solution  or  biniodide  of  mercury  in 
water  (1  in  5000),  and  drained,  while  the  point  where  the  capsule  has  been 
penetrated  should  be  excised. 

(2)  In  the  case  of  larger  wounds  which  obviously  penetrate  the  joint, 
careful  aseptic  measures  should  be  practised,  all  lacerated  and  dirty  skin, 
fascia,  &c,  cut  away,  foreign  bodies  removed,  working  steadily  down  to 
the  joint  (after  enlarging  the  wound  if  necessary),  which  is  cleansed  mechani- 
cally, removing  debris,  cutting  away  badly  damaged  tissue,  and  washing 
out  with  weak  antiseptic  lotions  ;  the  capsule  is  then  sutured  and  the  joint 
drained  for  two  to  three  days.  Should  this  treatment  prove  successful 
in  avoiding  infection  the  joint  should  be  moved  within  a  week  of  the  injury, 
and  active  movements  and  massage  instituted  to  prevent  adhesions  forming. 
Should,  however,  the  joint,  in  spite  of  these  measures,  become  grossly 
infected,  it  should  be  freely  opened,  irrigated,  and  drained ;  while  if  the 
process  still  spreads,  free  incisions  as  for  cellulitis,  or  later  excision  of  the 
joint,  removal  of  sequestra,  or  amputation,  may  be  necessary. 

Dislocations.  By  this  term  is  understood  a  displacement  of  the 
articular  surfaces  of  a  joint.  Other  structures  beside  joints  may  be  dislo- 
cated, as  nerves,  tendons,  the  lens  of  the  eye,  the  penis,  &c. 

Dislocations  of  joints  take  place  from  three  main  causes  : 

(1)  By  violence  or  traumatic  dislocation. 

(2)  From  disease,  which  is  discussed  in  the  section  on  Diseases  of  Joints. 

(3)  From  some  antenatal  cause ;  such  are  described  as  congenital  dis- 
locations. The  only  variety  at  all  common  is  that  of  the  hip,  and  is  described 
under  affections  of  this  joint. 

In  the  present  section  only  traumatic  dislocations  will  be  considered. 

Traumatic  dislocations  are  classified  in  a  manner  similar  to  fractures  ; 
thus  : 

Simjde  or  closed  dislocations  are  distinguished  from  compound  or  open 
dislocations  in  that  the  former  do  not  communicate  with  the  outside  by  a 
wound,  while  the  latter  do  so. 

Complicated  dislocations  are  associated  with  injury  of  vessels,  nerves, 
viscera,  &c. 


\    rEXTBOOK  OF  SURGERY 

»  !oniplete  dislocations  are  such  that  the  articular  surfaces  are  entirely 
rated,  while  m  partial   dislocations  or  subluxations  the  separation  is 

only  partial,  some  portion  of  these  surfaces  still  remaining  in  contact. 

ture-dislocations  have  been  described  under  fractures. 

irrenl  dislocations  need  no  explanation. 
Dislocations  are  more  common  in  adults  than  children,  in  whom  separa- 
tion ol  epiphyses  till  the  same  place,  the  epiphyseal  junction  being  a  weak 
spot,  while  in  old  persons  fractures  near  joints,  e.g.  the  neck  of  the  femur, 
are  more  usual  ;  the  osseo-ligamentous  mechanism  gives  way  under  stress 
at  its  weakest  point.  Some  dislocations,  however,  are  certainly  more 
common  in  children  than  in  adults,  e.g.  dislocation  backwards  of  the  forearm 
at    the    elbow-joint,    because    of    the    relatively    slight    development    of    the 

coronoid  process  in  children.     The  violence  producing  dislocations  may  be  : 

(</)  Externa]  and  either  direct  or  indirect,  usually  the  latter,  (b)  Internal 
or  muscular  violence,  which  often  causes  dislocation  of  the  lower  jaw  or 
humerus.     Recurrent  dislocations  are  often  due  to  muscular  violence. 

Pathology.  To  allow  of  complete  dislocation  taking  place,  there  is 
usually  a  rupture  of  the  capsule  of  the  joint,  the  end  of  one  of  the  hones 
escaping  through  this:  sometimes  the  capsule  may  he  only  stretched. 
Some  of  the  ligaments  and  muscles  will  also  he  torn  or  overstretched.  As 
a  result  of  all  this  tearing  and  stretching  there  will  be  a  gross  effusion  of 
blood  and  lymph  into  and  around  the  joint,  which,  if  the  dislocation  remains 
unreduced,  will  become  organized  and  prove  a  great  obstacle  to  reduction 
later.  If  a  dislocation  he  reduced  at  once  the  condition  becomes  equivalent 
to  a  severe  sprain  with  a  weak  place  in  the  capsule  of  the  joint.  As  a  rule 
alter  reduction  the  capsule  heals  readily  and  the  joint  becomes  restored, 
in  time,  to  its  original  state.  If.  however,  strong  ligaments  are  torn,  bony 
fragments  separated,  or  if  the  dislocation  be  made  to  recur  by  a  too  early 
and  violent  use  of  the  joint,  permanent  weakness  results  and  a  tendency  to 
repeated  re-dislocation,  through  a  healed,  smooth  hole  in  the  capsule. 

I  nreduced  Dislocation.  There  are  two  possibilities  in  this  condition: 
(a)  Ankylosis  occurs,  or,  in  other  words,  the  effusion  around  the  displaced 
bones  becomes  organized  and.  together  with  the  contraction  of  torn  muscles 

and  ligaments,  fixes  tl ads  (irmly  in  their  new, abnormal  position  so  thai 

but  slight  movement  is  possible. 

(b)  A  new  joint  is  formed  (pseudo- or, better,  neo-arthrosis)  between  the 
displaced  end  ol  the  more  mobile  of  the  two  bones  and  the  part  of  the 
other  bone  against  which  it  lies.  Such  a  condition  is  especially  prone  to 
arise  in  the  shoulder  or  hip.  In  such  cases  a  new  capsule  is  formed,  cartilage 
ot  a  SOrl  arises  to  give  an  articulating  surface  in  the  new  socket,  and  the 
surrounding  muscles  adjust  themselves  to  the  new  conditions,  becoming 
shorter  or  longer  as  aecessary,  so  that  a  fair  amount  of  movement  is  possible. 
Such  new  joints  are.  however,  very  prone  to  suffer  from  osteo-arthritic 
changes,  with  considerable  disability. 

Signs  <i,,<l  Diagnosis.  This  turns  on:  (I)  Local  swelling  and  effusion 
of  blood.     (2)  An  abnormal  position  of  the  ends  of  the  bones  forming  the 


REDUCTION  OF  DISLOCATIONS  253 

joint,  which  is  detected  by  noting  the  relations  of  the  subcutaneous  bony 

prominences  surrounding  the  joint,  or  the  end  of  one  bone  is  felt  in  some 
position  other  than  the  socket  in  the  other  bone  where  it  should  rest. 
(3)  Unnatural  fixity  of  the  part ;  the  joint  will  not  bend  as  a  normal  joint 
should  do.  (4)  Alteration  in  the  length  of  the  limb  as  compared  with 
the  sound  side.  (5)  Deformity  in  dislocations  is  usually  well  marked  and 
often  more  noticeable  than  in  fractures. 

The  signs  of  local  trauma,  if  severe,  may  readily  mask  and  render  difficult 
the  appreciation  of  the  bony  prominences  about  a  joint. 

Treatment.  The  main  obstacles  to  reduction  of  a  dislocation,  i.e.  replacing 
the  ends  of  the  bones  in  position,  are  : 

(1)  Spasm  of  the  muscles  surrounding  the  joint,  which  suggests 
in  treatment  :  (a)  Certain  manipulations  in  the  position  of  the  limb. 
(b)  Extension  to  tire  out  the  contracting  muscles,  (e)  The  use  of  a  general 
anaesthetic  to  cause  muscular  relaxation. 

(2)  The  interlocking  of  bony  prominences  such  as  the  coronoid  in  the 
case  of  the  elbow,  necessitating  suitable  manipulation. 

(3)  The  size  and  position  of  the  rent  in  the  capsule. 

(4)  The  interposition  of  ligaments  and  tendons,  which  are  difficulties 
also  overcome  by  manipulations  suitable  to  each  case.  In  old-standing 
dislocations  in  addition  there  will  be  : 

(5)  Contracted  muscles,  tendons,  and  ligaments. 

(6)  Adhesions  from  organizing  of  the  effusion. 

(7)  Alterations  in  the  structure  of  the  ends  of  the  bones. 

Methods  of  Reduction,  (a)  The  most  generally  useful  method  of  reduc- 
tion is  manipulation,  which  consists  in  putting  the  joint  through  certain 
movements  which  vary  with  the  joint  dislocated,  and  which  aims  at  causing 
the  dislocated  end  to  retrace  its  steps  back  to  its  socket,  at  the  same  time 
relaxing  muscles,  ligaments,  and  capsule  as  may  be  necessary  to  achieve 
this  result.  Manipulation  to  reduce  dislocations  depends  on  a  correct 
understanding  of  the  anatomy  of  the  joint  in  question  and  a  knowledge  of 
the  course  travelled  by  the  dislocated  end  of  the  bone.  Anaesthesia  is  often 
necessary  in  these  cases,  and  it  is  well  to  remember  that  among  the  fatalities 
of  anaesthesia  its  use  for  reducing  dislocations  ranks  high,  chiefly  because 
it  has  been  employed  in  robust,  muscular  men  in  the  prime  of  life,  often 
not  over-well  prepared  for  anaesthesia.  Chloroform  has  been  chiefly  respon- 
sible for  these  fatalities,  and  for  this  reason  ether  should  always  be  given 
the  preference  in  such  cases. 

(6)  Extension,  i.e.  traction  of  the  limb  in  its  long  axis,  is  a  very  service- 
able method  and  acts  chiefly  by  tiring  out  the  spasmodically  contracted 
muscles.  It  is  doubtful  if  it  is  justifiable  to  use  more  force  in  extension 
than  can  be  exerted  by  the  surgeon  pulling  on  the  limb  after  securing  a 
good  hold  with  a  jack-towel  fastened  by  means  of  a  clove-hitch  round  the 
limb.  The  plan  of  using  pulleys  to  increase  the  power  may  be  disastrous, 
ending  in  tearing  the  skin  or  rupturing  vessels  or  nerves,  sometimes  fracturing 
bones.     Extension  forms  a  useful  adjunct  to  manipulation,  especially  in 


\    rEXTBOOK  OF  SURGERY 

dislocations  <»f  the  shoulder,  and  should  be  employed  in  moderation  under 
anaesthesia  between  attempts  at  reduction  by  manipulation.  It  these 
methods  tail  it  is  more  reasonable  t<>  proceed  to  open  operation  rather 
than  to  exerl  enormous  brute  force  with  pulleys. 

Thf  act  of  reduction  is  accompanied  by  a  curious  sucking  or  smacking 
sound  which  is  characteristic,  and  that  reduction  has  occurred  is  proved 
by  the  bones  being  found  to  be  in  thru  normal  position,  and  by  thf  passive 
movements  of  the  joint  being  possible  on  manipulation. 

(-■)  Reduction  by  open  operation  is  seldom  oeeded  in  recent  cases,  and 
recourse  should  only  he  made  to  this  plan  after  several  attempts  to  reduce 
by  manipulation  have  failed.  In  old-standing  dislocations  operation  is 
far  more  often  needed;  but  even  in  these  cases  a  good  trial  should  he 
made  of  manipulation  and  extension,  as  these  methods  are  often  successful 
in  cases  of  two  or  three  months'  standing  or  even  longer. 

The  treatment  of  dislocations  after  reduction  is  similar  to  that  of  sprains, 
viz.  rest  and  elastic  pressure  for  three  days,  then  massage  and  pressure 
by  bandaging  over  wool  to  reduce  the  effusion  :  active  movements  may  be 
commenced  in  about  three  days  in  most  cases,  but  movements  likely  to 
cause  re-dislocation  should  be  avoided  for  six  weeks  at  least,  e.g.  in 
-  of  dislocation  of  the  shoulder,  abduction  of  the  arm  above  the 
horizontal. 

Old-standing  Dislocations.  In  the  treatment  of  these  cases  a  considera- 
tion of  the  patient-  age  and  the  seat  of  dislocation  is  necessary  in  deciding 
on  treatment.  In  some  instances,  if  the  dislocation  is  not  readily  reduced 
by  manipulation  it  may  be  better  to  leave  the  joint  dislocated  and  strive 
by  massage  and  movements  to  obtain  a  good  false  joint.  This  plan  may 
dopted  in  dislocations  of  the  shoulder  in  old  people  where  there  is  no 
pressure  on  the  nerves  and  vessels  caused  by  the  dislocated  head  of  the 
humerus.  If  it  is  decided  that  it  is  worth  while  to  make  a  determined  attempt 
to  improve  the  condition  and  manipulative  reduction  fails,  various  courses 
are  suitable  in  different  ca 

(a)  The  dislocation  may  be  explored  by  open  operation,  the  retaining 
bands  divided  the  socket  hollowed  out  from  the  fibrous  tissue  which  often 
fills  it,  and  the  bones  forced  into  proper  position  by  manipulation  and 
-ion. 

{b)  Failing  to  reduce  by  this  method,  the  joint  may  be  excised,  e.g. 
the  shoulder  or  elbow;  this  is  inferior  in  result  to  the  former  plan,  but 
arthroplasty  may  take  the  place  of  excision  with  advantage. 

{<■)  The  hone  may  be  left  dislocated  and  a  better  position  of  the  limb 
obtained  by  osteotomy  near  the  dislocated  end.  e.g.  in  old-standing  disloca- 
tion of  the  hip  with  much  flexion  of  the  thigh. 

'  om  pound  dislocations  are  treated  much  as  coi  n  pom  id  fracture.-,  thorough 
mechanical  and  chemical  cleansing  being  performed  and  the  dislocation 
reduced.  Should  the  dislocated  end  be  grossly  damaged,  primary  excision 
may  be  I- 


RUpture  OF  MUSCLES  AND  TENDONS  253 

INJURIES  OF  MUSCLES  AND  TENDONS 
Injuries  to  muscles  may  be  subcutaneous  or  open,  i.e.  associated  with 
wounds.  Of  subcutaneous  injuries  we  find  contusions  and  ruptures.  Con- 
tusions need  but  little  mention.  When  severe  they  may  result  in  the 
formation  of  a  hsematoma  ;  in  any  case  there  will  be  some  localized  and 
indurated  swelling  of  the  muscle  which  is  tender  and  painful,  particularly 
if  the  muscle  be  put  in  action. 

In  most  instances  such  results  of  contusion  readily  subside  on  massage, 
but  suppuration  may  occur,  needing  the  knife  :  in  severe  contusions,  partial 
rupture  of  the  muscle  is  not  uncommon. 

Rupture  of  Muscles.  This  may  be  complete  or  incomplete. 
Incomplete  rupture  results  from  over-use  or  contusion  of  muscle.  The 
signs  resemble  those  of  contusion,  viz.  pain  on  putting  the  muscle  in  action, 
tenderness  on  palpation,  and  perhaps  a  localized  swelling,  which  may  be 
a  large  haematoma.  Elastic  pressure  by  bandaging  over  wool  and  massage 
commencing  on  the  third  day,  moderate  active  use  after  a  week,  will  usually 
result  in  rapid  cure.  Another  form  of  incomplete  rupture  is  where  the 
muscle-sheath  is  torn  and  on  contraction  the  muscular  belly  bulges  through 
the  gap  ;  if  causing  inconvenience,  open  operation  and  suturing  the  sheath 
is  indicated. 

Complete  rupture  of  muscles  is  due  to  sudden  violent  contraction,  such 
as  may  occur  in  tetanus,  or  athletic  exercise,  especially  in  middle-aged 
untrained  persons.  The  condition  is  detected  by  the  loss  of  function  of 
the  muscle,  and  usually  by  local  swelling  ;  further,  when  the  muscle  is 
put  in  action  the  two  halves  swell  up  as  soft  masses  with  a  well-marked  gap 
between  them  unless  the  rupture  is  close  to  the  tendon,  when  only  one 
soft,  flabby  swelling  will  form.  Muscles  commonly  ruptured  are  the  biceps 
humeri  and  the  rectus  femoris  :  the  adductor  longus  is  ruptured  inten- 
tionally in  reducing  congenital  dislocations  of  the  hip  bv  the  bloodless 
method.  Repair  of  muscle  is  by  organization  of  the  extra vasated  blood  and 
lymph  and  formation  from  this  of  a  fibrous  scar  tissue.  Such  scars  tend 
to  stretch  and  weaken  the  muscle  considerably. 

Treatment.  In  complete  rupture  of  muscles  there  is  considerable  risk 
of  the  fibrous  union  stretching,  and  thus  the  muscle  comes  to  have  an  extra 
tendon  in  its  centre  which  greatly  reduces  its  power.  In  practically  all 
cases  where  the  patient  is  in  good  health  ruptured  muscles  should  be  united 
by  suture  ;  attempts  to  get  the  ends  in  apposition  by  bringing  the  points 
of  attachment  nearer  together  are  of  but  feeble  effect.  The  muscle  should 
be  freely  exposed,  the  ends  secured  and  sutured  with  strong  chromic  catgut ; 
if  the  sutures  show  signs  of  cutting' out.  some  mattress  sutures  should  be 
inserted  some  distance  from  the  ends  of  the  divided  portions  as  tension 
sutures,  and  the  edges  accurately  united  with  smaller  sutures.  Wounds  of 
muscle  are  treated  in  a  similar  manner. 

Tendons  are  ruptured  by  excessive  muscular  effort  or  divided  in  wounds. 
In  subcutaneous  ruptures  the  lesion  is  detected  by  failure  of  action  of 


\    fEXTBOOK  OF  SURGERY 


certain  tendons,  e.g.  the  flexors  or  extensors  of  one  or  more  fingers,  &c. 
Tendons  are  mosl  often  divided  in  wounds  <>f  the  wrist  ;  and  in  such  cases 
it  is  important  to  make  certain  how  many  tendons  are  divided  so  that 
none  escape  union  l>y  suture,  and  also  bo  see  whether  nerves  are  divided 
aa  w,.i|.     h   seems  unnecessary  to  point   out  that  nerves  should  not  be 


"EL 


lt.tr 


Fig.  83.  Operations  to  supply  a  Lose  of  substance  to  a  tendon.  1.  By  turning  up 
tii|>~  from  t  he  ends.  2,  By  employing  a  piece  oi  neighbouring  tendon.  :'>.  Tendon- 
lengthening  by  the  Z  operation.  4.  Suture  oi  tendon,  showing  the  l"ii'_r 
approximation  and  the  short  apposition  sutures.  5,  Shortening  a  tendon  by 
oblique  incision.  •  >.  Reinforcing  the  tendon  ol  a  paralysed  muscle:  part  of  the 
tendon  of  a  healthj   muscle  ie  interlaced  (and  sutured)  into  tin-  paralysed  tendon 

mar  its  insertion. 

united  to  tendon,-,,  though  this  mistake  lias  occurred  on  more  than  one 
■ion.  In  this  type  of  case,  viz/severe  wounds  about  the  wrist,  the 
power  ot  motion  (finger  and  wrist  movements)  should  be  tested  first,  as 
well  as  the  sensation,  this  will  give  a  fairly  shrewd  idea  of  the  extent  of  the 
damage:  the  wound  should  be  enlarged  so  that  the  retracted  upper  ends 
of  the  tendons  can  be  brought  down  readily  (they  often  retrapt  three  inches), 
while  by  flexing  the  wrisl  and  fingers  the  distal  ends  can  be  brought  into 


ISCH.EMK    CONTRACTURE  OF  MUSCLES  255 

the  wound.  Tendons  should  be  sutured  with  fine  or  medium  chromic  catgut, 
and  it  is  best  to  place  a  mattress  suture  in  each  some  distance  from  the 
cut  ends  and  one  or  two  sutures  close  to  the  ends  to  secure  good  apposition 
of  these  :  the  nerves  are  sutured  as  described  in  the  section  on  Nerve  Injuries. 
(Fig.  83.  4.) 

Loss  of  substance  of  tendons  can  be  supplied  by  flaps  turned  down  from 
each  end  or  by  transplating  the  distal  end  into  a  neighbouring  uninjured 
tendon  which  has  a  similar  function.  Passive  and  active  movements 
should  be  commenced  within  ten  days  or  the  tendons  will  become  so  adherent 
in  their  sheaths  that  the  part  will  lose  much  of  its  use.     (Fig.  83,  1,  2.  <>.) 

Dislocation  of  Tendons.  This  is  likely  to  occur  in  tendons  which  act 
around  a  pulley,  whether  ligamentous  or  bony,  e.g.  the  peroneus  longus 
tendon.  The  condition  is  diagnosed  by  pain,  impaired  movement,  and 
weakness  in  the  situation  of  the  tendon  and  feeling  the  tendon  in  an  abnormal 
position. 

Treatment  consists  in  exploring  the  tendon  by  open  operation  and  fashion- 
ing a  new  groove  of  periosteum,  aponeurosis  or  bone. 

Ischemic  Contracture  of  Muscles  (Volkmann).  This  term  is  applied 
to  a  condition  of  fibrosis  and  contracture  of  muscles  due  to  a  certain  type  of 
injury,  and  is  usually  met  with  after  fractures  which  have  been  too  tightly 
splinted  or  bandaged,  but  may  also  follow  the  blocking  of  the  main  artery 
of  a  limb.  Ischeemic  contracture  is  most  often  met  with  in  the  muscles  of 
the  forearm,  especially  in  children.  There  is  often  other  evidence  of  over- 
zealous  splinting  in  the  shape  of  pressure  sores  and  venous  congestion. 
Its  more  frequent  occurrence  in  children  rather  than  adults  is  probably 
due  to  the  greater  freedom  of  anastomotic  circulation  and  power  of  recovery 
of  the  tissues  in  young  subjects  ;  in  adults  similar  pressure  would  probably 
cause  gangrene.  The  condition  of  ischemic  contracture  is  one  of  degenera- 
tion of  the  muscle-fibres,  which  are  gradually  replaced  by  fibrous  tissue, 
and  the  latter  contracts.  Experimentally  little  success  has  been  met  with 
in  trying  to  reproduce  this  condition  in  animals  by  tight  bandages,  the  usual 
results  being  gangrene  or  flaccid  paralysis.  Injury  to  nerves  is  often  present 
in  ischaemic  contracture,  but  probably  is  not  a  factor  of  causation.  As 
mentioned,  the  condition  is  usually  noted  in  the  forearms  of  children  which 
have  been  put  up  in  splints  or  plaster  for  fractures  about  the  elbow- joint 
or  forearm.  The  appearance  of  this  contracture  is  characteristic,  since  it 
involves  principally  the  flexors  of  the  fingers  and  wrist  and  the  pronator 
radii  teres  ;  the  elbow  is  semi-flexed  and  the  hand  pronated  ;  the  two 
distal  phalanges  of  fingers  are  flexed,  the  digits  extended  at  the  metacarpo- 
phalangeal joint ;  the  wrist  is  also  flexed.  In  less  severe  cases  the  wrist  may 
not  be  flexed  ;  in  the  more  severe  the  wrist  and  metacarpophalangeal  joints 
are  flexed  as  well  as  the  distal  phalanges.     (Fig.  95,  III,  IV.) 

That  the  contracture  is  due  to  the  shortening  of  the  muscles  is  shown 
by  forcibly  overflexing  the  wrist,  when  the  fingers  can  be  extended  on  the 
hand.  The  electrical  reactions  of  the  muscles  are  normal,  showing  that 
the  contracture  is  not  due  to  nerve  injury.     This  condition  is  progressive, 


\    rEXTBOOK  OF  SURGERT 

the  contracting  muscles  gradually  dragging  the  finger  into  the  palm,  making 
the  grasp  very  weak. 

D  '  •  ■-  ».  The  muscles  (especially  the  flexors)  are  cord-like,  hard,  and 
u len  to  feel,  and  the  flexed  position  of  the  fingers  will  readily  distin- 
guish from  such  conditions  as  ulnar  or  inner-cord  paralysis,  or  Dupuytren  s 
contracture,  to  which  there  is  some  slighl  resemblance. 

In  the  early  Btages  after  removal  of  the  splints  or  bandage  the  fingers, 
hand,  and  forearm  are  congested,  Bwollen  and  oedematous,  and  the  contrac- 
ture develops  rapidly,  whereas  contractures  following  paralyses  are  always 
of  much  slower  development. 

Treatm  /</.  (a)  Prevention  is  important  by  avoiding  too  tight  ban) la L'ine; 
ent  fractures. 

(b)  In  the  early  si  ages,  contracture  of  the  muscles  is  prevented  by  splint- 
ing t  he  tingers  and  wrist  so  as  to  keep  t  hem  extended, and  employing  massage 
and  passive  movements  in  the  direction  of  extension  ;  this  will  cure  the 
less  severe  cases. 

(c)  In  more  severe  instances  it  will  be  necessary  to  lengthen  the  flexor 
tendons  of  the  fingers  and  wrist  and  of  the  tendon  of  pronator  radii  teres, 
splitting  them  longitudinally  and  dividing  in  a  Z  manner,  then  re-suturing 
with  sufficient  elongation.     (Fig.  83.  3.) 

(d)  The  bones  of  the  forearm  may  be  shortened  by  removal  of  an  inch 
or  so.  Good  results  have  been  obtained  with  both  the  last  two  methods  ; 
the  tendon  lengthening  seems  the  more  rational,  as  in  the  latter  method 
there  is  some  danger  of  non-union  of  the  bones. 

Whatever  the  form  of  treatment,  prolonged  massage,  and  both  passive  and 
active  movements  are  needed,  for  it  must  be  remembered  that  a  great  part 
of  the  muscles  is  destroyed  and  time  is  necessary  for  the  remainder  to 
hypertrophy. 

Further  consideration  of  this  condition  will  be  found  under  Affections 
of  the  Wrist  and  Hand  (p.  481). 


CHAPTER  XII 

INJURIES  OF  SPECIAL  REGIONS,  CHIEFLY  REFERRING   TO 

FRACTURES,    DISLOCATIONS    AND    INJURIES   TO   MUSCLES 

AND   TENDONS 

Injuries  about  the  inner  end  of  the  clavicle  :  Fractures  of  the  shaft  of  the 
clavicle  :  Injuries  about  the  shoulder  :  Of  the  scapula  :  Of  the  arm  and  shaft 
of  the  humerus  :  Of  the  elbow-joint  :  Of  the  forearm  :  Of  the  wrist  :  Of  the 
hand  and  fingers  :  Of  the  pelvis  :  Of  the  hip  :  Of  the  femoral  shaft  :  Of  the  knee  : 
Of  the  tibia  and  fibula  :  Of  the  ankle  :  Of  the  foot. 

In  this  chapter  we  confine  ourselves  to  the  injuries  of  the  limbs.  Injuries 
to  the  skull  and  spinal  column  are  considered  in  the  section  on  the  Xervous 
System,  while  injuries  of  the  ribs  and  sternum  are  described  under  the 
Surgery  of  the  Thorax. 

A.     INJURIES   OF   THE  UPPER   LIMB 

(1)  Injuries  about  the  Inner  End  of  the  Clavicle  and  Sterno- 
clavicular Joints.  The  following  are  described  :  (a)  Sprains  ;  (6)  dis- 
locations ;  (c)  separations  of  the  inner  epiphysis  of  the  clavicle ;  (d)  frac- 
tures of  the  inner  end  of  the  clavicle. 

Surgical  Anatomy.  The  clavicle,  which  forms  the  only  osseo-ligamentous 
bond  of  union  between  the  upper  limb  and  the  trunk,  articulates  at  its 
inner  end  with  the  sternum  by  a  joint  which  depends  for  its  security  chiefly 
on  two  ligaments,  both  passing  up  from  the  cartilage  of  the  first  rib — 
(a)  the  rhomboid,  passing  up,  out,  and  slightly  back  to  the  lower  border  of 
the  clavicle  ;  (b)  the  interarticular  fibro-cartilage,  passing  up  to  the  upper 
edge  of  the  articular  surface,  crossing  the  face  of  the  latter.  The  strength 
of-  these   ligaments  renders   dislocation   upward   or   backward  unusual. 

Diagnosis  of  injuries  in  this  region  turns  on  the  position  of  the  deformity, 
the  clavicle  being  easily  palpable  throughout  its  length  and  being  readily 
measured.  A  sprain  will  show  only  a  fluctuating  swelling  about  the  inner 
end  of  the  clavicle  (sterno-clavicular  joint),  with  some  bruising  or  dis- 
coloration in  severe  instances.  In  dislocations  the  inner  end  of  the  bone 
will  be  in  a  different  position  from  that  of  its  fellow  on  the  sound  side — 
being  more  prominent  if  the  dislocation  be  up  or  forward,  less  prominent  if 
the  dislocation  is  backward,  being  then  sunken  into  the  soft  tissue  in  front 
of  the  trachea.  In  case  of  separation  of  the  inner  epiphysis  or  fracture 
close  to  the  inner  end  of  the  clavicle  there  will  be  a  projection  up  or  forward 
of  the  inner  end  of  the  outer  fragment,  which  can  be  distinguished  from 
the  inner  end  of  the  dislocated  bone  by  its  being  more  abrupt  in  outline, 
by  the  injured  clavicle  being  shorter  than  its  fellow,  and  by  noting  that 
i  257  17 


\    rEXTBOOK  OF  SURGERY 

the  small  inner  fragment  carrying  the  articular  end  is  in  its  normal  position 
attached  to  the  Bternum  and  first  rib.  But  often  in  fractures  in  tins 
situation  there  is  very  slight  displacement. 

(a)  Sprains  are  sufficiently  described  above. 

Treatment.  Slinging  the  arm  for  a  few  days  and  massage  will  soon 
cure. 

(0)  Dislocations  are  rare  owing  to  the  Btrength  of  the  ligaments  already 
mentioned  ;  they  are  generally  due  to  indirect  violence  applied  to  the 
.  ute.  end  of  the  hone.  e.g.  falls  on  the  point  of  the  shoulder.  Displacement 
occurs   in   three  directions:    (1)  forward,   (2)  backward,   (3)  upward. 

(1)  In  dislocations  of  the  clavicle  forward  the  inner  end  is  displaced 
down  as  well  as  forward  so  that  it  can  be  readily  felt  in  front  of  the  manu- 
brium sterni. 

(2)  In  backward  dislocation  the  inner  end  lies  behind  the  upper  part 
of  the  sternum,  and  a  depression  is  noted  where  the  inner  end  of  the  bone 


Fig.  84.     Positions  of  fractures  of  the  clavicle. 

should  be.  The  displaced  inner  end  causes  compression  of  the  trachea, 
oesophagus  and  great  vessels  of  the  neck,  resulting  in  dyspnoea,  dysphagia, 
and  congestion  of  the  face  with  cyanosis. 

(3)  The  upward  dislocation  is  rare  ;  the  end  of  the  bone  is  readily  felt 
above  the  sternum  and  may  compress  the  trachea. 

To <it merit.  All  these  dislocations  may  be  reduced  by  drawing  the 
shoulders  backward,  the  patient  sitting  and  the  surgeon  placing  his  knee 
between  the  shoulders  behind,  to  exercise  counter-pressure.  It  may  be 
noted  that  this  method,  which  is  the  basis  of  the  treatment  of  all  forms  of 
injury  to  the  clavicle,  has  as  its  object  extension  of  the  clavicle  in  its  long 
axis.  The  extension  is  assisted  by  manipulating  the  end  of  the  bone  back 
into  place.  When  reduced  the  position  is  maintained  by  keeping  the 
upper  end  of  the  clavicle  drawn  back  and  outward  and  the  elbow  forward 
by  Sayre's  strapping  or  the  three-handkerchief  method,  as  detailed  under 
Fractures  of  the  Shaft  of  the  Clavicle. 

(c)  Separation  of  the  Epiphysis  of  the  Clavicle.  There  is  only  one  epiphysis 
to  the  clavicle,  situated  at  the  inner  end  ;  it  unites  with  the  diaphysis 
at  the  age  of  twenty-five,  and  is  about  half  an  inch  long.  Therefore  an 
injury  to  the  inner  end  of  the  clavicle,  with  deformity  and  shortening  of 
the  bone,  and  the  inner  end  of  the  bone  still  in  situ,  occurring  in  a  patient 
under  twenty-five,  will  probably  be  a  separation  of  this  epiphysis.  The 
inner  end  of  the  outer  larger  fragment  is  usually  displaced  upwards. 

(tl)  Fracture  of  the  inner  end  of  the  clavicle,  i.e.  to  the  inner  side  of  the 
rhomboid   ligament,   is  uncommon,   and  may  be  due  to  direct  violence. 


FRACTURES  OF  THE  CLAVICLE  259 

There  is  usually  uo  displacement  but  simply  swelling,  tenderness,  and 
possibly  crepitus  at.  the  seat  of  fracture,  though  if  there  has  been  great 
violence  and  the  rhomboid  ligament  is  torn,  the  inner  end  of  the  outer 
fragment  may  be  displaced  forward,  backward,  or  upward. 

Treatment  of  separation  of  the  epiphysis  or  fracture  in  this  position 
depends  on  the  displacement  and  deformity  ;  if  there  is  none,  the  arm 
may  be  carried  in  a  sling  for  two  to  three  weeks,  massage  and  movements 
being  used  early.  Where  there  is  displacement,  this  should  be  reduced  by 
pulling  the  shoulders  backwards  and  retaining  with  Sayre's  strapping. 
Failing  this,  in  cases  where  there  is  much  deformity  open  operation  and 
plating  will  be  advisable. 

(2)  Fractures  of  the  Shaft  of  the  Clavicle.  Anatomy.  This  bone 
is  subcutaneous  throughout  its  extent  so  that  deformity  from  fracture  is 
readily  noted  ;  in  spite  of  its  proximity  to  the  skin,  compound  fractures 
in  this  situation  are  extremely  rare.  The  clavicle  has  an  important  relation 
to  the  axillary  vessels  and  the  brachial  plexus,  over  which  it  lies,  being 
separated,  however,  by  the  subclavius  muscle,  which  protects  these  impor- 
tant structures  when  fracture  takes  place,  so  that  they  are  but  seldom 
injured.  Fracture  of  the  shaft  of  the  clavicle,  which  is  one  of  the  commonest 
of  fractures,  occurs  between  the  rhomboid  and  trapezoid  ligaments,  usually 
about  the  middle  of  the  forward  convexity  of  the  bone — most  often  from 
indirect  violence,  as  from  falls  on  the  point  of  the  shoulder  or  on  outstretched 
hand  ;  less  often  from  direct  violence,  such  as  blows  on  the  clavicle.  The 
deformity  produced  when  the  fracture  is  complete  is  characteristic.  The 
clavicle  is  a  strut  which  keeps  the  upper  lmib  away  from  the  trunk,  and 
in  keeping  it  away  enables  the  muscles  which  are  attached  to  the  limb 
from  above  (chiefly  the  trapezius)  to  keep  the  shoulder  up.  The  conse- 
quences of  breaking  this  strut  are  that  the  whole  shoulder  travels  inward 
and  swings  downward  about  its  attachment  to  the  head  and  spine.  But 
in  addition  to  keeping  the  upper  limb  away  from  the  trunk,  the  clavicle 
further  prevents  the  shoulder  from  rotating  inward,  so  that  when  fractured 
there  is  an  inward  rotation  of  the  whole  upper  limb  from  the  shoulder. 
The  usual  displacements  in  fracture  of  this  bone  are  :  (a)  The  inner  fragment 
maintains  practically  its  normal  position,  for  although  the  sterno-mastoid 
muscle  tends  to  pull  it  upward,  the  rhomboid  ligament  prevents  this  occur- 
ring to  any  marked  degree,  (b)  The  outer  fragment,  together  with  the 
shoulder  and  upper  limbs,  falls  forward  and  inward,  being  at  the  same  time 
slightly  rotated  inward.  In  children  incomplete  or  green-stick  fractures 
of  this  bone  are  common  ;  the  deformity  is  slight,  but  irregularity  of  the 
clavicle  can  be  felt  on  palpation  of  the  subcutaneous  surface,  and  later  the 
appearance  of  a  mass  of  callus  corroborates  the  diagnosis. 

Diagnosis.  Power! essness  of  the  limb  and  the  above-described  deformity 
of  the  shoulder,  together  with  the  irregularity  of  the  bone,  with  or  without 
crepitus,  render  diagnosis  easy.  It  should  be  noted,  however,  that  children 
are  fairly  often  brought  up  with  loss  of  power  in  the  arm  and  some  vague 
history  of  injury.     Such  cases  often  turn  out  to  be  injury  to  the  brachial 


260  \  TEXTBOOK  OF  SURGERY 

plexus  01  acute  anterior  poliomyelitis  (infantile  paralysis)  of  the  upper 
limb.  Fracture  of  the  clavicle,  therefore,  should  not  be  diagnosed  unless 
deformity  or  crepitus  is  detected  in  the  length  of  the  clavicle  ;   in  obscure 

-  the  X-rays  may  help,  [n  severe  injuries,  usually  due  to  direct  violence. 
the  fracture  may  be  compound  or  complicated  by  injuries  of  the  brachial 
plexus  or  axillary  vessels,  bul  such  complications  are  rare. 

Treatment.  Reduction  is  easily  accomplished  by  placing  the  knee 
between  the  shoulders  and  pulling  the  latter  back  and  upwards.  When 
reduced   the  correcl    position   is   maintained   by   various  means,   of  which 


FlG.  85.     Sayre'fi  strapping  for  fractures 

of  the  clavicle.     The  first  strap  drawing 

the  upper  end  of  the  humerus  back. 


Fig.  86.     Sayre's  strapping  for  fractures 

of  the  clavicle.     The  second  strap  brings 

the    elbow   forwards    and   elevating   the 

whole  of  the  upper  limb. 


the  most  generally  useful  is  that  of  Sayre  ;  but  the  handkerchief  and  recum- 
bent methods  may  prove  serviceable  in  some  instances. 

(n)  In  Sayre's  method  the  upper  end  of  the  humerus  is  pulled  back 
by  one  piece  of  strapping  which  acts  as  a  fulcrum,  while  a  second  piece  of 
b1  rapping  pulls  the  elbow  forward  and  elevates  the  whole  arm  and  shoulder — 
the  whole  idea  being  to  use  the  humerus  as  a  lever  with  which  to  cause 
extension  of  the  clavicle.     The  technique  is  as  follows  (Figs.  85,  86)  : 

( I )  A  piece  of  strapping  three  inches  wide  and  one  foot  longer  than  the 
circumference  of  the  patient  is  taken  and  fastened  loosely  round  the  arm 
of  the  patient  on  the  side  of  fracture,  a  loop  being  made  in  one  vw\  with 
a  large  safety-pin  and  the  sticky  side  being  outward.  The  loop  is  loose  to 
allow  of  a  padding  of  boric  lint  and  wool  being  placed  around  the  arm  to 
prevent  chafing.  This  strap  is  now  taken  backwards  round  the  body 
horizontally,  with  the  sticky  side  inwards,  and  applied  to  the  thorax  so 
that  the  humerus  is  pulled  backwards.     The  second  strap,  which  is  longer, 


SAYRE'S   STRAPPING 


261 


is  placed  on  the  sound  shoulder,  round  the  back,  over  the  elbow  of  the 
injured  side,  which  is  at  the  same  time  pushed  forwards  ;  it  passes  along 
the  forearm  of  this  side,  which  is  flexed,  and  ends  where  it  commenced, 
overlapping  its  other  end  on  the  sound  shoulder.  Two  points  are  to  be 
noted  in  connected  wTith  this  strap  :  (a)  No  hole  should  be  cut  to  receive 
the  olecranon,  as  is  often  advised,  since  with  a  hole  in  this  situation  there 
is  a  chance  of  the  strapping  pressing  on  the  ulnar  nerve  and  causing  ulnar 
paralysis  (Sherren).     (b)  In  adults  the  hand  on  the  injured  side  should 


Fig.  87. 


Three- handkerchief  method  for  fractured  clavicle 
back  with  two  handkerchiefs. 


pulling  the  shoulders 


not  be  included  in  this  strap,  or  it  may  become  exceedingly  stiff  and  perhaps 
never  fully  recover  ;  in  children  such  stiffness  does  not  occur  and  inclusion 
of  the  hand  makes  for  security.  The  two  pieces  of  strapping  are  strengthened 
by  a  third  horizontal  piece  embracing  the  trunk  and  flexed  arm  on  the 
injured  side  ;  a  bandage  over  the  whole  completes  the  fixation  of  the 
fracture. 

(2)  The  three-handkerchief  method  is  useful  as  first-aid  treatment  or  in 
some  cases  of  this  fracture  in  children  without  displacement.  Two  large 
handkerchiefs  are  folded  to  form  soft  cords,  which  are  placed  over  each 
shoulder,  through  the  axillae,  under  the  arm,  and  knotted  first  separately 


\  TEXTBOOK  OF  SURGERY 

and  then  together  at  the  back,  thus  pulling  the  shoulders  backward.  The 
third  handkerchief  is  employed  as  a  sling  to  pull  the  elbow  up  and  forward. 
The  principle  involved  is  the  same  as  in  the  previous  method,  bu1  it  is  far  less 

secure  and  efficienl  (Figs.  87,  88). 

(3)  The  patient  may  be  kept  in 
bed  with  a  sand-bag  between  the 
shoulders  and  the  elbow  on  a  pillow, 
while  layers  of  strapping  pass  OveT 
the  site  of  the  fracture  from  breast 
to  scapula.  This  plan  is  well  re- 
puted, but  outside  the  world  of 
female  rank  and  fashion  few  patients 
will  submit  to  the  inconvenience 
and  waste  of  Mine  incurred  by  the 
use  ot  this  method  for  such  a  trifling 
accident  as  a  broken  collar-bone. 

Union  will  take  place  in  two  to 
four  weeks,  depending  on  the  age  of 
the  patient  :  the  strapping  should 
b.'  retained  during  this  period.  The 
strapping  should  be  changed  once  a 
week  at  least,  and  at  each  change 
the  shoulder  moved  to  prevent  for- 
mation of  adhesions.  Attention  has 
already  been  called  to  the  danger  of 
fixing  the  hand  in  adults,  especially 
in  old  patients.  Attn-  the  strapping  is  discarded  the  arm  should  be  kept 
in  a  sling  for  ten  to  fourteen  days,  and  massage  and  increasingly  stronger 
active  and  passive  movements  made  use  of. 

(3)  Injuries  about  the  Shoulder-Joint.  A  large  variety  of  injuries 
aie  met  with  in  this  region,  including  sprains,  dislocations,  and  fractures, 
viz.  fracture-;  of  the  inner  end  of  the  clavicle,  injuries  to  the  acromio- 
clavicular joint,  injuries  to  the  shoulder- joint  and  to  the  subdeltoid  bursa, 
fract  ures  of  the  scapula,  and  Eracl  ures  and  separation  of  the  epiphyses  of  the 
upper  end  of  the  humerus. 

Surgical  Anatomy  ok  the  Shoulder.  The  bony  points  about  the 
shoulder- joint  are  the  outer  part  of  the  clavicle  ami  acromion  process  of 
the  scapula,  which  are  subcutaneous  throughout.  It  should  be  noted 
that  the  acromion  tonus  tin1  point  of  the  shoulder,  extending  a  good  inch 
beyond  the  acromioclavicular  joint,  the  position  of  which  is  represented 
by  a  liii"  drawn  up  the  middle  of  the  interior  surface  of  the  pendent 
arm.  and  which  is  readily  felt  on  palpation.  Behind  the  tip  of  the  acro- 
mion is  a  well-marked  tubercle  on  the  acromion  (the  deltoid  tubercle). 
which  is  a  useful  point  to  take  as  a  starting-point  in  measuring  the 
length  of  the  arm.  'I  he  coracoid  process  of  the  scapula  can  be  felt 
deeply  just     below   the   outer    end    of    the    clavicle,   overlapped  by  the 


B8.     The  three-handkerchief  method  of 
treating    a    fractured    clavicle,    showing   the 
third  handkerchief   in   position   slinging  the 
elbow  up  and  fqrwards. 


ANATOMY  OF  THE   SHOULDER  263 

inner  fibres  of  the  deltoid.  The  vertebral  border  of  the  scapula  can 
be  rendered  prominent  by  placing  the  hand  on  the  opposite  shoulder, 
while  the  angle  stands  out  if  the  fore  arm  be  flexed  and  brought  behind 
the  back.  The  upper  end  of  the  humerus  is  surrounded  by  muscles,  but 
the  great  tuberosity  can  be  palpated  through  the  deltoid  (it  will  be  noted 
that  the  external  condyle  of  the  humerus  normally  points  in  the  same 
direction  as  the  great  tuberosity),  while  the  head  as  well  as  the  inner  side 
of  the  neck  of  the  humerus  can  be  just  reached  by  deep  palpation  in  the 
axilla. 

The  claviculo-scapular  articulation  is  chiefly  formed  by  the  strong 
and  rarely  ruptured  conoid  and  trapezoid  ligaments,  which  bind  the  outer 
part  of  the  clavicle  to  the  coracoid  process,  while  the  acromioclavicular 
joint  is  simple  and  of  weak  construction. 

The  scapulo- humeral,  or  shoulder- joint,  is  the  most  mobile  joint  in  the 
body  and  the  most  frequently  dislocated,  since  the  mechanism  is  adapted 
rather  for  mobility  than  strength.  The  receiving  articular  surface  (glenoid 
fossa)  is  shallow,  but  the  capsular  socket  is  strengthened  above,  in  front, 
and  behind  by  its  reinforcement  with  the  strong  subscapularis  and  external 
rotator  tendons  (supra-  and  infra-spinatus  and  teres  minor)  as  well  as  the 
coraco-humeral  ligament,  while  in  addition  the  acromion  and  coracoid 
processes  with  the  coraco-acromial  ligament  and  deltoid  muscle  form  a 
secondary  socket  above ;  consequently  dislocation  upwards  is  unknown 
without  severe  fracture.  The  weak  point  in  the  capsule  of  this  joint  is 
below,  where  there  are  no  reinforcements,  and  this  is  the  direction  in  which 
dislocation  occurs.  Between  the  deltoid  and  the  capsule  is  the  large  sub- 
deltoid bursa,  while  outgrowths  of  the  synovial  membrane  of  joint  form 
bursal  protrusions  following  the  long  tendon  of  the  biceps  and  under  the 
subscapularis  tendon. 

General  Diagnosis  of  Injuries  about  the  Shoulder.  The  patient 
'should  sit  in  a  good  light  with  both  shoulders  bare,  and  inspection  should  be 
from  in  front  and  behind.  Inspection  may  reveal  swelling  and  bruising, 
which  are  common  to  many  injuries  such  as  fractures  or  dislocations.  More 
important  is  it  to  note  the  dropping  of  the  shoulder  in  fracture  of  the  clavicle  ; 
the  loss  of  fullness  or  "  flattening  "  of  the  shoulder,  with  relative  projection 
of  the  acromion,  due  to  absence  of  the  head  of  the  humerus  from  its  normal 
position  in  dislocations  of  this  bone  or  fractures  of  the  surgical  neck  of  the 
scapula  ;  abnormal  positions  of  the  arm,  e.g.  abduction  in  dislocations, 
and  the  difference  of  the  direction  of  the  axes  of  the  humerus  on  the  injured 
compared  with  the  sound  side,  are  also  found  in  such  cases.  Palpation  of 
the  clavicle  or  acromion  may  reveal  local  tenderness  and  swelling,  abnormal 
mobility,  or  crepitus  indicating  fracture.  The  vertebral  border  and  angle 
may  be  palpated  as  described  above,  or  the  body  grasped  in  two  hands  and 
attempts  made  to  discover  mobility  or  crepitus.  By  deep  palpation  the 
coracoid  may  be  tested  for  similar  defects.  The  great  tuberosity  of  the 
humerus  is  palpated  through  the  deltoid  or,  if  dislocated,  detected  in  the 
region  of  the  coracoid,  and  further  information  gained  by  gently  rotating 


264 


A  TEXTBOOK  OF  SURGERY 


the  arm  while  palpating  the  tuberosity;    if  the  tuberosity  'lot's  not  move 
with  the  shaft  there  must  be  fracture  of  the  surgical  neci  or  of  the  tuberosity, 

while  crepitus  may  be 
noted.  In  cases  where 
flattening  of  the  shonl- 
dei  is  in  it  «m1.  elevation 
of  1  he  el  bow  may  reduce 
this  deformity  and  cre- 
pitus will  probably  be 
felt,  suggesting  frac- 
ture of  the  neck  of  the 
scapula.  Two  other 
methods  of  examina- 
tion are  most  valuable 
when  dislocation  of  the 
shoulder  is  suspected  ; 
these  are  : 

(1)  The  Straight-edge 
or  Hamilton  s  Test.  Nor- 
mally a  straight-edge  or 
long  ruler  cannot  rest 
on  the  acromion  and 
the  external  condyle 
of  the  humerus  at  the 
same  time,  since  the 
presence  of  the  bulging 
head  and  great  tuber- 
osity of  the  humerus 
prevents  this.  Should 
the  straight-edge  touch 
both  these  points  at 
once  the  humeral  head 
is  out  of  place,  either 
being  dislocated  from 
its  socket  or  because 
the  neck  of  the  scapula 
is  broken  and  the  hu- 
merus is  displaced  with 
the  smaller  fragment. 

(2)  Dugas's  Test  con- 
sists in  placing  the  hand 
on  the  opposite  shoul- 
der :  normally  when 
thi-  is  'Ion.-  the  elbow  can  readily  touch  the  side  of  the  body,  but  if 
iti''  head  of  the  humerus  is  dislocated  this  bone  is  adducted  and  the 
elbow  cannot   be    made  to   touch   the  body   while   the   hand  is  on  the 


Fig.  89.  Diagrams  to  illustrate  the  application  of  the  straight- 
edge (Hamilton)  and  Dugas's  test  in  cases  of  injury  about  tin' 
shoulder.  The  action  of  the  deltoid,  pectoralis  major  and 
latissimus  dorsi  is  indicated.  A.  Normal  shoulder.  The 
Btraight-edge  i-  kepi  away  from  the  tip  of  the  acromion  by  the 
bead  of  the  humerus  ;  the  elbow  is  close  to  the  side.  li.  Sub- 
coracoid  dislocation.  The  straight  edge  can  rest  on  the  tip  of  the 
acromion  ;  tin-  elbow  La  away  from  I  be  side.  ( '.  Fracture  of  the 
I  neck  of  the  humerus.  The  straight-edge  cannot  touch 
the  acromion.  'I'hc  elbow  is  away  from  the  Bide  but  readily 
replaced  (with  crepetus).  I).  Dislocation  of  the  humerus  with 
fracture  of  the  surgical  neck  :  the  straight  edge  rests  on  the 
acromion  while  the  elbow  comes  to  the  side. 


INJURIES  OF  THE  OUTER  END  OF  THE  CLAVICLE       265 

opposite  shoulder.  These  tests  are  useful  in  the  diagnosis  of  obscure  injuries 
about  the  shoulder  occurring  in  fat  persons.  Finally,  in  these  days  of 
litigation  X-ray  examination  should  be  made  in  all  cases  of  severe  or  obscure 
injuries  about  the  shoulder,  since,  while  this  may  help  to  prevent  gross 
errors  such  as  missing  dislocations,  it  is  the  only  way  by  which  small  frac- 
tures of  the  glenoid  fossa,  interligamentous  fractures  of  the  clavicle,  and 
the  more  difficult  fracture  dislocations  of  the  upper  end  of  the  humerus 
can  be  diagnosed  with  anything  approaching  certainty. 

(a)  Fractures  of  the  Outer  End  of  the  Clavicle.  These  maybe 
between  or  outside  the  conoid  and  trapezoid  ligaments. 

(1)  Fractures  between  the  ligaments  (interligamentous)  are  due  to 
direct  violence  and  are  difficult  to  diagnose  without  X-ray  examination, 
since  as  a  rule  there  is  no  separation.  Local  swelling  and  tenderness, 
possibly  abnormal  mobility  and  crepitus,  may  be  detected  ;  while  later, 
callus  will  develop  at  the  seat  of  fracture. 

Treatment.  The  arm  should  be  slung  for  about  three  weeks  and  massaged 
from  the  outset. 

(2)  Fractures  outside  the  ligaments.  Here  the  inner  and  larger  fragment 
remains  in  normal  position  while  the  outer  may  be  dragged  forward  and 
downward  by  the  weight  of  the  arm,  but  in  these  cases  also  there  may  be 
no  displacement. 

Treatment.  Where  there  is  displacement  extension  by  Sayre's  method 
should  be  used,  otherwise  slinging  the  arm  and  massage. 

(b)  Injuries  to  the  Acromioclavicular  Joint.  Sprains  and  dis- 
locations occur  here,  the  former  being  fairly  common,  sometimes  with 
subluxation  of  the  joint.  The  cause  is  generally  a  fall  on  the  point  of 
the  shoulder.  In  dislocations  the  acromion  may  be  displaced  above  or 
below  the  clavicle,  the  former  condition  being  rare.  Diagnosis  is  easy 
from  the  superficial  position  of  both  bones  ;  but  it  should  be  noted 
that  the  clavicle  normally  projects  somewhat  above  the  acromion,  so  that 
sometimes  subluxation  of  the  joint  is  diagnosed  when  there  is  little  more 
than  a  sprain. 

Treatment.  Reduction  is  easy  by  pulling  the  shoulder  up  and  backward, 
but  it  is  difficult  to  maintain  this  position  even  by  Sayre's  method  and  pulling 
down  the  projecting  clavicle  with  strapping  over  it.  Fortunately,  such 
cases  do  well,  even  though  perfect  reduction  is  not  maintained,  if  treated 
with  massage  and  exercises.  Cutting  down  and  fixing  the  ends  has  been 
suggested  but  this  does  not  seem  necessary. 

(c)  Fractures  of  the  Scapula.  Fractures  of  this  bone  may  be  divided 
into  three  main  groups  :  (1)  of  the  acromion,  (2)  of  the  body,  (3)  about  the 
neck  and  glenoid  fossa,  including  the  coracoid  ;  and  are  as  a  rule  caused 
by  direct  violence. 

(1)  Fractures  of  the  acromion  process  are  caused  by  falls  or  blows  on 
the  point  of  the  shoulder. 

Signs,  flattening,  and  dropping  of  the  shoulder  will  be  noted,  and  on 
palpation  a  gap  will  be  felt  in  the  subcutaneous  acromion  ;    while  crepitus 


A  TEXTBOOK  OF  SURGERY 


and  abnormal  mobility  will  be  detected,  the  former  on  raising  and  rotating 

the  arm. 

Treatment.  The  elbow  should  be  flexed  and  raised  with  a  wide  sling 
and  the  arm  bandaged  to  the  side,  relaxing  the  tense  deltoid  ;  a  pad  in  the 
axilla  will  help  to  maintain  good  position.  The  arm  should  be  kept  in  this 
position  two  to  four  weeks  and  passive  movements  commenced  after  the  first 

week,  when  the  fixing  bands  are  re- 
adjusted. The  movements  should 
be  confined  at  first  to  rotation  of  the 
shoulder.  Union  may  be  fibrous, 
especially  when  the  fracture  is  near 
the  tip  of  the  process. 

(2)  Fractures  of  the  body  are 
due  to  direct  violence  and  are 
often  comminuted.  The  lines  of 
fracture  usually  extend  more  or 
less  horizontally  across  the  body, 
but  may  radiate  in  a  stellate 
manner  from  the  neck  or  pass 
vertically  ;  nd  parallel  with  the 
vertebral  border.  Separation  of 
the  fragments  is  usually  trivial,  the 
portions  of  the  bone  being  firmly 
bound  together  by  the  strong 
aponeurosis  covering  the  spinati 
and  subscapularis  muscles. 

Diagnosis    may    not    be    easy 
owing  to  the  amount  of  bruising, 
but   firmly  grasping  the  bone  with  both  hands,  abnormal  movement  and 
crepitus  can  as  a  rule  be  elicited. 

Treatment.  The  side  of  the  body  should  be  strapped  right  up  into  the 
axilla,  the  straps  passing  well  beyond  the  mid-line  on  each  side  and  covering 
the  body  of  the  lion,',  as  lor  fractured  ribs,  high  up  ;  at  the  same  time  the 
arm  should  he  placed  in  a  wide  sling;  massage  and  gentle  movements  of 
the  shoulder  may  be  commenced  in  three  days. 
(."»)  Fracture  about  the  neck  and  coracoid  process. 
(a)  Fractures  of  the  coracoid  process  vary  in  extent  from  slight  cases 
where  only  the  last  half-inch  of  the  process  is  broken  off  to  those  in  which 
the  whole  process  is  broken  off  and  the  line  of  fracture  extends  into  the 
glenoid  fossa.  There  is  seldom  much  displacement  as  the  conoid  and 
trapezoid  ligaments  tend  to  retain  the  fragments  in  position. 

Signs.  In  mosl  instances  bruising,  abnormal  movement,  and  crepitus 
on  deep  palpation  alone  are  noted,  but  if  the  tip  only  is  broken  off  this 
may  be  pulled  down  by  the  short  head  of  the  biceps  and  pectoralis  minor. 

Treatment.  Where  there  is  no  displacement  a  sling  and  massage  will 
suffice.     II  there  is  wide  separation  the  only  resource  is  open  operation, 


Fig. 


90.     Diagram  of  various  fractures  which 

OCCUI  ill  the  scapula. 


INJURIES  OF  THE  SHOULDER-JOINT  267 

the  separated  tip  being  fixed  with  wire  or  screws  if  the  patient's  condition 
does  not  contra-indicate  such  measures. 

(b)  Fractures  of  the  glenoid  fossa.  The  lower  part  of  the  fossa  is  usually 
broken  oft*  obliquely. 

Signs.  Effusion  into  the  joint  and  possibly  crepitus.  Accurate  diagnosis 
is  only  possible  with  the  help  of  X-rays. 

Treatment.  Slinging  the  arm,  with  early  massage  and  movements,  is 
the  usual  treatment  ;  but  as  osteo-arthritis  is  very  likely  to  follow,  it  will 
be  sounder  policy  to  explore  the  joint  and  probably  remove  the  loose  frag- 
ment, or  fix  it  in  position,  if  large  enough. 

(c)  Fracture  of  the  anatomical  neck.  Here  the  whole  glenoid  fossa 
is  broken  oft  the  rest  of  the  scapula  and  displaced  somewhat  downwards. 

Diagnosis.  Slight  flattening  of  the  shoulder  and  apparent  lengthening 
of  the  arm,  the  head  of  the  humerus  being  rather  lower  with  regard  to 
the  acromion  than  is  normal ;  this  can  be  readily  reduced  with  crepitus 
by  raising  the  elbow.     A  certain  diagnosis  will  need  X-rays. 

(d)  Fracture  of  the  si  rgical  neck.  Here  the  glenoid  fossa  and  the 
coracoid  process  are  broken  off  in  one  piece,  the  line  of  fracture  passing 
through  the  suprascapular  notch  and  below  the  origin  of  the  triceps  (long 
head)  ;  the  separated  fragment  will  be  displaced  downward,  carrying  with 
it  the  humerus. 

Diagnosis.  The  shoulder  is  flattened,  the  arm  being  over-long  when 
measured  from  the  deltoid  tubercle  of  the  acromion  to  the  external  condyle  ; 
the  head  of  the  humerus  and  the  coracoid  process  are  both  felt  too  low. 
In  contra-distinction  to  a  subglenoid  dislocation  of  the  humerus  (in  which 
also  the  arm  is  too  long)  in  this  injury  the  deformity  of  lengthening  is 
readily  reduced  by  raising  the  elbow,  the  reduction  being  accompanied  by 
crepitus.     X-ray  investigation  will  render  the  matter  clear. 

Treatment.  That  usually  advised  in  the  last  two  conditions  is  to  raise 
the  flexed  elbow  with  a  sling,  which  reduces  the  deformity,  after  placing  a 
pad  in  the  axilla  ;  the  arm  is  then  bandaged  to  the  side.  Rotation  of  the 
shoulder- joint  should  be  commenced  early  (after  a  week)  to  prevent  stiffness 
of  the  shoulder,  and  daily  massage  instituted,  the  arm  being  still  in  the 
sling,  to  prevent  the  fragment  dropping. 

(d)  Injuries  of  the  Shoulder- joint.  These  comprise  :  (1)  Sprains 
and  bruises  of  (a)  the  shoulder-joint,  (b)  of  the  subdeltoid  bursa.  (2)  Dis- 
locations of  the  shoulder-joint. 

(la)  Violence  applied  to  the  shoulder,  short  of  that  necessary  to  produce 
fracture  or  dislocation,  frequently  causes  sprains  or  strains — the  signs  of 
which  are  pain,  inability  to  move  the  joint  to  any  great  extent,  and  perhaps 
effusion  into  the  joint,  which  can  be  detected  by  noting  the  swelling  under 
the  deltoid,  which  makes  the  shoulder  appear  wider  when  looked  at  from 
the  side,  and  by  palpating  high  in  the  axilla,  when  the  head  of  the  humerus 
is  less  easily  felt  than  normal  owing  to  the  effusion,  and  possibly  fluctuation 
may  be  detected. 

(16)  In  other  instances  the  injury  affects  chiefly  the  subdeltoid  bursa. 


A  TEXTBOOK  OF  SURGERY 

The  signs  are  similar  to  sprains  of  the  shoulder,  but  the  pain  and  disability 
are  principally  on  abducting  the  shoulder  and  not  on  movements  of  rotation, 
and  the  swelling  is  entirely  below  the  deltoid,  no  swelling  in  the  axilla  being 
detected. 

Dislocation  of  the  Shoulder-joint.  This  is  by  far  the  commonest  of 
all  dislocations.  The  reasons  for  this  have  already  been  stated,  viz.  the 
insufficiency  of  the  Bockei  formed  by  the  glenoid  fossa,  the  weakness  of  the 
lower  part  of  the  capsule,  and  the  wide  range  of  movements  of  which  the 
joint  is  capable.     (Fig.  89,  B.) 

Dislocation  is  usually  caused  immediately  by  indirect  violence,  from 
falls  on  the  outstretched  hand  with  the  arm  abducted,  but  occasionally 
from  direct  violence  to  the  joint  itself. 

In  practically  every  case  the  head  of  the  humerus  leaves  the  socket 
through  the  lower  part  of  the  capsule  (the  arm  being  abducted)  and  is  then 
below  the  glenoid  fossa.  From  this  primary  position  secondary  deviation 
occurs  forward  or,  less  commonly,  backward,  in  accordance  with  the  direc- 
tion and  degree  of  the  violence.  Three  of  such  secondary  positions  of 
the  head  are  usually  described,  making  with  the  primary  the  following 
varieties  of  dislocation. 

(a)  The  subglenoid  or  primary  position,  when  the  head  is  immediately 
below  the  glenoid  cavity. 

(b)  The  subspinous,  when  the  head  passes  backward  to  rest  below  the 
spine  of  the  scapula. 

(c)  The  subcoracoid,  when  the  head  has  travelled  some  distance  forward 
and  lies  under  the  coracoid  process. 

(d)  The  subclavicular,  when  the  head  has  travelled  further  inwards  and 
lies  internal  to  the  coracoid  below  the  clavicle. 

Besides  these,  rare  cases  of  supracoracoid  dislocation  are  described 
where  the  head  has  passed  above  the  coracoid,  always  associated  with 
fracture  of  this  process  or  the  acromion. 

General  Pathology.  The  capsule  is  usually  torn  through  in  its  lower 
part,  tint  may  be  merely  stretched  in  the  subglenoid  variety.  The  muscles 
attached  to  the  tuberosities  are  stretched  or  torn  and  there  is  considerable 
effusion  of  blood  and  lymph  into  the  joint  and  its  surroundings,  which  later 
become  organized,  and  if  the  dislocation  is  unreduced  lead  to  difficulty  of 
reduction,  and  if  it  be  reduced  will,  if  care  in  the  treatment  be  not  taken, 
lead  to  impaired  movement. 

Signs.  In  addition  to  pain,  bruising,  swelling,  and  inability  to  use  the 
joint,  the  following  signs  are  found  in  cases  of  dislocation  of  the  shoulder: 

(1 )  Flattening  of  the  shoulder  with  apparent  prominence  of  the  acromion  ; 
the  flattening  is  due  to  the  absence  of  the  head  and  tuberosities  under  the 
deltoid,  which  normally  give  the  shoulder  its  rounded  appearance,  i.e. 
the  glenoid  fossa  is  empty. 

(2)  Absence  of  the  head  is  further  determined  by  the  straight-edge  test 
(Hamilton),  since  the  s1  raight-edge  can  only  touch  the  acromion  and  external 
condyle  if  the  glenoid  fossa  be  void  of  the  humeral  head. 


DISLOCATIONS  OF  THE  SHOULDER-JOINT  269 

(3)  The  displaced  head  can  be  detected  elsewhere,  under  the  spine  of  the 
scapula  or  below  the  clavicle  or  coracoid.  It  will  be  noted  that  the  head 
can  be  located  by  rotating  the  humerus  at  the  elbow  and  feeling  the  head, 
in  its  new  position,  rotate  with  the  former. 

(4)  There  is  an  alteration  in  the  direction  of  the  axis  of  the  humerus, 
which  does  not  point  to  the  glenoid  fossa  but  to  some  point  internal  to  this, 
i.e.  the  elbow  is  abducted. 

(5)  This  abduction  of  the  elbow,  which  points  away  from  the  side,  is  made 
clear  by  Dugas's  test,  for  with  the  hand  on  the  opposite  shoulder  the  elbow 
cannot  be  made  to  touch  the  side. 

Less  important  points  are  that  the  axillary  folds  are  lower,  the  vertical 
measure  of  the  axillary  circumference  is  increased,  and  the  length  of  the 
arm  is  altered.     Turning  now  to  the  different  varieties  of  dislocation  : 

(a)  The  Subglenoid  Dislocation.  Here  the  head  of  the  humerus  is  below 
the  glenoid  fossa,  resting  on  the  outer  border  of  the  scapula  in  front  of  the 
long  head  of  the  triceps.  The  capsule  is  torn  below,  the  external  muscles 
attached  to  the  tuberosities  torn  or  stretched.  The  arm  is  elongated.  The 
brachial  plexus,  especially  the  inner  cord,  may  be  injured  (see  Injuries  to 
Nerves). 

An  uncommon  type  of  subglenoid  dislocation  is  described  in  which  the 
abduction  of  the  arm  is  so  great  that  this  remains  extended  above  the  head 
(luxatio  erecta). 

(b)  The  subcoracoid  is  the  commonest  variety,  the  head  of  the  humerus 
resting  on  the  front  of  the  neck  of  the  scapula  just  below  the  coracoid  and 
above  the  tendon  of  the  subscapularis  muscle,  which  is  very  tense.  The 
external  rotators  are  torn  or  stretched,  in  which  latter  case  the  humerus  is 
strongly  rotated  out :  if  the  rotators  are  torn  or  the  great  tuberosity  torn 
off,  the  arm  will  be  rotated  inwards  by  the  subscapularis  and  the  head  may 
travel  further  in  ;  this  is  sometimes  called  the  "  intracoracoid  "  variety 
(Malgaigne). 

Signs.  The  head  can  be  felt  under  the  coracoid,  the  elbow  projects 
backwards  as  well  as  away  from  the  side,  the  length  of  the  arm  is  unaffected. 

(c)  The  subclavicular  is  a  rare  condition  and  is  an  exaggeration  of  the 
preceding  form  :  the  head  is  behind  the  pectoralis  minor  on  the  ribs,  inside 
the  coracoid  and  below  the  clavicle.  There  is  much  laceration  of  the  rotator 
muscles. 

Signs.  The  head  is  felt  internal  to  the  coracoid,  the  arm  is  away  from 
the  side,  and  the  elbow  points  backward. 

(d)  The  subspinous  is  also  very  rare  :  the  head  of  the  humerus  rests 
on  the  dorsum  of  the  scapula  behind  the  glenoid  fossa,  sometimes  on  the 
edge  of  the  fossa  (subacromial  type  of  Malgaigne)  ;  the  arm  is  rotated 
inwards  by  the  tense  subscapularis  and  the  elbow  points  forward,  the 
forearm  lying  across  the  body. 

Signs.    The  arm  is  abducted,  the  elbow  pointing  forward ;   the  head  is 

felt  below  the  spine  of  the  scapula,  while  there  is  a  hollow  below  the  coracoid. 

Treatment.     Dislocations  of  the  shoulder  may  be  reduced  by  manipula- 


270 


A  TEXTBOOK  OF  SURGERY 


tii>n.  extension,  open  operation,  or  a  combination  of  these  methods,  with 
oi  w ithout  anaesthesia. 

(1)  Manipulation.  In  this  nirtln.il  an  attempt  is  made  to  cans.'  fche 
head  to  retrace  its  Bteps  through  the  rent  in  the  capsule  by  various  move- 
ments of  rotation  and  circumduction,  of  which  the  most  generally  useful 
for  forward  dislocations  is  the  following.  The  patient  is  laid  on  his  hack 
on  a  couch  and  steadied  by  an  assistant.  With  the  arm  at  the  side  the 
forearm  is  flexed  to  a  right  angle  and.  using  the  forearm  as  a  lever,  the 
arm    is    rotated  slowly  outwards    as   far   as   possible   without   damaging 


Pig.  '.m. 


KocheiV  method  of  reducing  dislocation  of  the  shoulder-joint. 
External  rotation. 


the  humerus  or  elbow-joint  (it  should  be  noted  that  this  is  a  very  easy 
manner  of  producing  a  spiral  fracture  of  the  humerus  if  great  force  be  used, 
bo  that  the  movement  is  performed  slowly  and  carefully)  ;  next,  while  still 
holding  the  arm  externally  rotated,  the  latter  is  adducted  strongly  across 
the  chest  and  finally  rotated  inwards.  As  a  rule  the  head  will  slip  back 
with  the  characteri-t  ie  sucking  noise  during  the  second  stage  of  manoeuvre. 
This  plan  is  known  as  Kocher's  method,  and  the  rationale  is  as  follows  : 
The  external  rotation  relaxes  the  tense  external  rotators,  which  are  strained 
over  the  glenoid  fossa  :  the  strong  adduction  of  the  elbow  causes  the  head 
to  travel  outwards,  since  the  humerus  is  fixed  to  the  scapula  mainly  by 
the  tense  deltoid  which  acts  as  t  he  fulcrum  lor  t  his  manoeuvre  :  the  internal 
tot  at  ion  i-  supposed  to  relax  the  capsule,  but,  as  already  remarked,  we  have 
generally  found  that  reduction  occurs  during  the  process  of  adduction. 

(2)  I  may  he  employed  when  Bingle-handed,  by  placing  the 

bight  of  a  clove-hitch  in  a  jack-towel  round  the  arm  above  the  elbow  ; 


REDUCTION  OF  A  DISLOCATED  SHOULDER  271 


Fig.  91a.     Adduction. 


Fig.  91b.     Internal  rotation. 


272  A  TEXTBOOK  OF  SURGERY 

then,  with  the  patient  recumbent,  the  surgeon  places  the  ball  of  the  foot 
(not  the  heel,  or  the  brachial  plexus  may  be  injured)  in  the  axilla  and  his 
back  in  the  loop  of  the  towel  and  simply  leans  backwards,  quietly  but 
firmly.  Extension  is  made  in  this  way  tow  aids  the  feel  of  the  patient  : 
after  a  few  minutes  the  head  will  often  pass  again  into  the  socket.  If  this 
•  lees  not  take  place  after  ten  minutes  manipulation  should  be  tried  again, 
when  it  will  often  prove  successful.  Instead  of  a  foot  in  the  axilla,  counter- 
extension  may  be  made  by  an  assistant  with  the  loop  of  another  towel  in 
the  axilla,  pulling  towards  the  patient's  head,  and  when  employing  this 
method  slow  abduction  of  the  arm  to  a  right  angle  with  the  axis  of  the 


Fig.  92.     Reducing  a  dislocated  shoulder  by  the  towel  and  foot-in-axilla  method. 

patient's  body  and  rotation  of  the  humerus  may  be  practised.  Extension 
with  the  arm  above  the  patient's  head,  although  sometimes  successful,  is 
not  a  method  to  be  recommended,  as  injury  to  the  brachial  plexus  is  likely 
to  result  from  the  unavoidable  stretching  of  this  important  structure. 
Where  there  is  difficulty  anaesthesia  should  be  induced,  but  owing  to  the 
dangers  of  chloroform  in  these  cases  open  ether  will  be  the  anaesthetic  of 
choice.  A  brief  description  of  the  method  employed  by  hunting  men 
when  suffering  from  dislocation  of  this  joint  will  close  the  consideration 
of  reduction  by  extension.  The  patient — dismounted,  of  course — leans  over 
a  five-barred  gate  and  firmly  grasps  the  lowest  bar  he  can  reach  with  the 
affected  arm,  so  that  the  top  of  the  gate  presses  well  up  into  the  axilla,  and 
allows  his  weight  to  hang  on  the  opposite  side  of  the  gate  to  that  grasped 
by  the  hand.  The  arm  is  thus  extended  by  the  grasping  hand  and  the  top 
of  the  gate  gives  counter-extension  in  the  axilla  and  pushes  the  head  of 
the  bone  out  towards  its  proper  place.     This  method  requires  some  hardi- 


OLD-STANDING  DISLOCATIONS 


273 


hood,  but  at  least  is  unlikely  to  damage  the  plexus  and  needs  no  assistance. 
In  cases  of  the  rare  dislocation  backward  (subspinous)  extension  may  be 
employed  as  before ;  when  practising  manipulation  the  movements  will 
naturally  have  to  be  reversed,  i.e.  the  arm  is  rotated  inward  to  relax  the 
tense  subscapularis  and  then  circumducted  outwards,  at  the  same  time 
pushing  the  head  into  place  with  the  thumb  of  the  other  hand. 

Treatment  of  Old-standing  Dislocations.  The  above  methods  will  nearly 
always  prove  successful  in  recent  cases  up  to  one  to  two  months,  when 
the  only  difficulties  to  be  overcome  are  the  spasm  of  muscles  and  sometimes 
the  size  of  the  rent  in  the  capsule.  In  cases  of  longer  standing  additional 
factors  will  make  the  difficulty  greater,  viz.  fibrous  tissue  about  the  head 


Fig.  93.     Reducing  a  dislocated  shoulder  ;  the  hunting  man's  method. 

and  in  the  glenoid  fossa,  shortening  of  muscles,  and  still  later,  alteration 
in  the  shape  of  the  bones  ;  in  such  case  open  operation  will  be  advisable 
after  a  fair  trial  of  extension  and  manipulation,  rather  than  to  make  use  of 
pulleys  and  other  mechanical  devices,  which  may  lead  to  rupture  of  the 
axillary  artery,  damage  to  the  plexus,  or  fracture  of  the  humerus.  The  joint 
may  be  approached  in  front  or  behind  ;    the  former  seems  the  better  plan. 

(1)  By  the  anterior  route  the  incision  is  in  the  interval  between  the 
deltoid  and  pectoral  muscles  and  the  head  exposed.  Adhesions  are  divided 
as  well  as  the  subscapularis  tendon,  the  external  rotators  partially  freed 
from  the  great  tuberosity,  and  the  glenoid  fossa  cleared  out ;  the  head  is 
then  manipulated  back  into  the  capsule.  Where  reduction  proves  impos- 
sible excision  of  the  head  will  be  needed.  The  results  are  fair  by  either 
method,  but  best  if  reduction  can  be  done. 

(2)  By  the  posterior  route  (Spencer)  the  glenoid  fossa  is  exposed  between 
the  teres  major  and  minor  muscles,  identifying  the  long  tendons  of  the 


1-71  \  TEXTBOOK  OF  SURGERY 

triceps  an<l  biceps  at  ilif  lower  ami  upper  borders  of  the  fossa  ;  the  latter 
cleared  out,  removing  redundant  fibrous  tissues,  ami  the  bone  manipulated 
into  place. 

After-treatment.    Whether    reduced    by    manipulation,    extension    or 

operation,  massage  ami  movements  should  be  commenced  within  three 
days  ;  at  first  movement  consists  in  gentle  rotation  of  the  head  ;  abduction 
of  the  arm  should  not  he  done  for  fourteen  days,  and  the  arm  should  not 
l>e  raised  above  the  horizontal  for  at  least  six  weeks. 

Recurrent  dislocation  may  he  the  result  of  too  early  abduction  of  a 
recently  dislocated  shoulder,  and  if  recurrence  is  allowed  to  occur  on  several 
-ions  the  capsule  becomes  lax  or  the  rent  in  the  capsule  becomes 
healed  at  the  edges  to  form  a  permanent  aperture,  so  that  dislocation  takes 
place  on  very  slight  movements,  such  as  sneezing,  &c.  Recurrent  disloca- 
tion is  not  infrequently  found  in  epileptics,  resulting  from  the  contortions 
of  a  ""  fit."  and  is  liable  to  result  from  separation  of  the  great  tuberosity 
at  the  original  dislocation. 

Treatment.  In  recent  cases  the  joint  should  be  reduced  by  manipulation 
and  massage,  and  exercises  practised  to  strengthen  the  muscles,  especially 
the  rotators,  but  abduction  should  be  limited  to  forty-five  degrees  by  an 
armlet  and  strap  attached  to  the  body,  especially  when  taking  active 
exercises.  Should  this  fail  after  some  months  or  the  case  be  of  old-standing, 
operative  treatment  is  indicated. 

Operative  Treatment  of  Recurrent  Dislocation.  The  joint  should  be 
exposed  by  anterior  incision  between  the  deltoid  and  pectoralis  major  ;  the 
long  head  of  the  biceps  is  carefully  retracted  and  the  insertion  of  the  sub- 
scapularis  removed  from  its  attachment  to  the  lesser  tuberosity  (the  sub- 
scapularis  is  supposed  to  assist  in  causing  the  re-dislocation)  ;  the  lax, 
lower  part  of  the  capsule  should  be  excised  and  sutured  or  puckered  up 
with  strong  sutures  and  so  obliterated  ;  the  tendon  of  the  subscapularis  is 
pushed  through  the  interval  between  the  coraco-brachialis  and  the  humerus 
and  sutured  to  the  deltoid  and  its  aponeurosis.  This  operation  gives  to 
a  very  strong  and  useful  shoulder. 

(e)  Fractures  of  the  Upper  End  of  the  Humerus.  The  following 
lesions  are  found  :  (1)  Fracture  of  the  anatomical  neck  ;  (2)  fracture  of 
the  surgical  neck  ;  (3)  separation  of  the  upper  epiphysis  ;  (4)  separation 
of  the  greal  tuberosity. 

(1)  Fracture  through  the  Anatomical  Neck,  i.e.  separation  of  the  head 
above  the  tuberosities  (intra  capsular  fracture),  occurs  in  old  persons  from 
direct  violence  and  is  often  impacted  ;  the  separation  is  usually  but 
slight  :  if  complete  separation  occurs  there  is  some  chance  that  the  head 
will  necrose. 

Diagnosis  without  radiogram  is  very  difficult,  and  before  this  method  of 
examination  became  common  these  fractures  were  considered  rare,  though 
in  fact  a  considerable  number  are  to  be  found  in  the  records  of  any  large 
hospital.  There  will  be  pain  and  impairment  of  movement ;  slight  flattening 
of  the  shoulder,  which  often  is  masked  by  the  associated  effusion  ;   the  head 


FRACTURES  OF  THE  NECK  OF  THE  HUMERUS 


275 


may  be  felt  loose  in  the  axilla  or  crepitus  noted ;   slight  shortening  should 
be  present,  though  hardly  enough  to  be  detected. 
Treatment  varies  with  the  nature  of  the  case  : 

(a)  Where  there  is  impaction  or  but  slight  displacement  the  forearm 
is  slung  from  the  wrist,  the  arm  lightly  bandaged  to  the  side,  massage  and 
movements  commenced  within  a  week. 

(b)  Where  there  is  considerable  separation  the  fragments  should  be 
manipulated  into  better  position  and  put  up  as  before,  but  with,  in  addition, 
a  pad  in  the  axilla  to  prevent  the 
lower  fragment  falling  inward.  Mas- 
sage should  be  started  within  a  week, 
but  passive  movements  not  till  two 
to  three  weeks. 

(c)  Where  there  is  gross  displace- 
ment such  as  inversion  of  the  head, 
so  that  union  is  impossible,  open 
operation  should  be  considered.  If 
the  patient's  condition  warrant  this, 
the  joint  is  exposed  by  the  anterior 
incision  and  usually  the  upper  frag- 
ment removed  and  the  lower  rounded 
off  to  form  a  new  head  ;  occasionally 
fixing  the  head  in  position  with  screw 
or  peg  may  seem  reasonable  treat- 
ment. 

(2)  Fracture  of  the  Surgical  Neck 
(extra-capsular  fracture),  i.e.  below 
the  tuberosities  and  rotator  muscles 
but  above  the  insertion  of  the  pecto- 
ral is  major,  latissimus  dorsi  and 
teres  major,  is  the  commonest  frac- 
ture in  this  region.  These  fractures 
may  be  due  to  direct  or  indirect  violence.  The  main  displacement  is  of 
the  lower  fragment,  the  upper  retaining  its  normal  position.  The  lower 
fragment  is  drawn  inward  by  the  latissimus  dorsi  and  pectoralis  major  and 
upwards  by  the  biceps  and  triceps,  and  the  elbow  is  abducted  by  the 
deltoid,  so  that  its  upper  end  lies  internal  to  the  upper  fragment  which 
it  overlaps  :  impaction  of  the  lower  into  the  upper  fragment  may  occur. 
(Fig.  89.  C.) 

Signs.  The  deformity  produced  somewhat  resembles  that  found  in 
subcoracoid  dislocation  of  the  shoulder,  in  that  the  elbow  points  away  from 
the  side  and  the  axis  of  the  bone  points  to  a  point  internal  to  the  glenoid 
fossa.  There  is,  however,  no  flattening  of  the  shoulder,  and  on  palpation 
the  great  tuberosity  can  be  felt  in  its  place  under  the  acromion  but  does 
not  move  on  rotating  the  humerus.  There  is  thus  abnormal  mobility  and 
not  fixity  of  the  limb,  and  during  manipulation  crepitus  will  often  be  noted, 


Fig.  94.  Treatment  of  fractures  of  the  neck 
of  the  humerus  by  slinging  the  fore-arm  at 
the  wrist  so  that  the  weight  of  the  arm  acts 
as  extension,  while  a  pad  in  the  axilla  (in  this 
case  a  U-shaped  piece  of  poroplastic)  prevents 
the  upper  end  of  the  lower  fragment  from 
being  drawn  inwards. 


276  A  TEXTBOOK  OF  SURGERY 

while  on  palpating  the  axilla  the  upper  end  of  the  lower  fragment  willbe 

[ell  as  a  projection  in  the  outer  wall  of  this  Bpace. 

Treatment.  The  deformity  is  reduced  by  traction  and  manipulation; 
thecorrecl  position  is  maintained  by  an  axillary  pad  or  ryshaPed  Por°- 
plastic  splint  in  the  axilla  to  prevent  the  upper  end  of  the  lower  fragment 
falling  inwards,  while  the  arm  is  shin-  from  the  wrist  to  produce  extension 
in  the  line  of  the  humerus  ;   the  arm  is  lightly  bandaged  to  the  side  and  a 


Fig.  'Jo.     Method  of  securing  replaced  fragments  of  a  fracture  with  a  steel  pin  passed 
longitudinally  ;   this  is  removed  in  two  to  three  weeks. 

cap  of  poroplastic  may  be  placed  over  the  shoulder  to  protect  this  from 
injury. 

When  in  spite  of  such  treatment  overlapping  of  the  fragments  results, 
open  operation  should  be  performed  by  an  incision  along  the  anterior  border 
of  the  deltoid  and  the  fragments  united  by  plating  or  driving  a  temporary 
steel  peg  vertically  through  the  junction  of  the  head  and  great  tuberosity 

us  to  pass  into  the  lower  fragment;  this  is  removed  in  three  weeks. 
These  cases  may  be  massaged  early;  passive  movements  should  not  be 
commenced  under  three  weeks ;  after  a  month  a  sling  alone  willbe  needed 
as  support. 

(3)  Separation  <<j  the  Upper  Epiphyses  of  the  Humerus.  The  upper 
epiphysis  comprises  in  its  limits  the  head  and  the  tuberosities,  and  is  formed 
of  three  centres  which  join  together  at  about  seven  years  and  join  the  shaft 


SEPARATION  OF  THE  UPPER  HUMERAL  EPIPHYSIS      277 


at  about  twenty-five.  Separation  of  this  epiphysis  occurs  between  these 
ages  and  usually  from  direct  violence.  The  upper  end  of  the  diaphysis  is 
bluntly  conical  and  fits  into  a  corresponding  depression  in  the  epiphysis  ; 
the  periosteum  is  firmly  attached  to  the  epiphysis  and  readily  strips  from 
the  diaphysis.  These  two  factors  render  displacement  slight  in  many 
instances,  but  should  the  upper  end  of  the  diaphysis  protrude  through  the 
stripped  sleeve  of  periosteum,  reduction  without  open  operation  is  almost 
impossible.  In  most  cases  some  of  the  dia- 
physis is  torn  off  with  the  epiphysis.  The 
displacement  is  usually  of  the  lower  fragment 
upward  and  forward,  the  epiphysis  remaining 
little  affected. 

Diagnosis.  The  direction  of  the  displace- 
ment of  the  upper  end  of  the  diaphysis  some- 
what resembles  that  found  in  a  subcoracoid 
dislocation,  but  the  head  and  great  tuberosity 
remaining  in  situ  can  be  felt  below  the  acro- 
mion and  the  fullness  of  the  shoulder  is  not 
lost.  The  age  of  the  patient  will  be  of  assist- 
ance, since  dislocations  are  less  c  mmon  under 
twenty-six.  Sometimes  the  upper  end  of  the 
diaphysis  will  be  felt  close  under  the  skin  in 
front,  rendering  the  fracture  nearly  compound. 

Treatment.  Under  anaesthesia  an  attempt 
should  be  mada  to  reduce  the  deformity  by 
traction  and  manipulation,  including  abduc- 
tion, till  the  arm  is  above  the  head  (Whitman). 
When  the  deformity  is  reduced,  or  if  there  is 
but  little,  the  limb  is  put  up  with  axillary  pad 
and  slung  from  the  wrist,  the  whole  lightly 
bandaged  to  the  trunk  as  in  fractures  of 
the  surgical  neck.  Whitman  advises  the 
application  of   a  plaster  spica  with  the  arm 

abducted  above  the  head.  Since  it  is  most  important  to  obtain  complete 
reduction  in  order  to  avoid  the  deformity  consequent  on  growth  in  unreduced 
cases,  and  should  this  not  be  satisfactory  after  manipulation  and  traction, 
the  seat  of  separation  should  be  explored  by  an  incision  along  the  anterior 
border  of  the  deltoid  and  the  fragments  levered  back  into  position.  As  a 
rule  it  will  not  be  necessary  to  fix  the  fragments  with  plate  or  screw, 
since  the  convenient  shape  of  the  surfaces  of  the  epiphysis  and  dia- 
physis, so  long  as  the  periosteal  sleeve  is  not  too  much  torn,  gives  secure 
apposition. 

(I)  Fracture  through  the  Great  Tuberosity.  This  process  is  most  commonly 
pulled  off  the  head  in  forward  dislocations  by  the  traction  of  the  external 
rotator  muscles,  being  an  alternative  lesion  to  rupture  or  stretching  of  these  ; 
less  often  the  tuberosity  is  knocked  off  by  direct  violence.     The  fragment 


Fig.  96.     Whitman's  method  of 
treating  a  separated  upper  epi- 
physis of  the  humerus  by  the 
abductioD  or  a  plaster  case. 


278 


A  TEXTBOOK  <>K  SURGERY 


is  pulled  back  and  out  ward  by  the  external  rotators  while  the  rest  of  the 
humerus  is  rotated  in  by  the  unopposed  subscapularis. 

s.  There  is  a  greai  increase  of  the  breadth  of  the  shoulder  as  seen 
Bideways;  sometimes  a  gap  can  be  fell  through  the  deltoid  between  the 
tuberosity  and  the  head  of  the  humerus,  and  crepitus  may  be  discovered  on 
rotating  the  bone.  When  occurring  with  an  anterior  dislocation  crepitus 
may  be  noted  on  reducing  the  dislocation,  hut  owing  to  the  swelling  the 


B 


Fig.  07.     Fracture  of  the  great  tuberosity  of  the  humerus  secured  with  a  screw. 

condition  is  likely  to  be  missed  unless  radiographs  be  taken  of  all  severe 
injuries  in  this  part. 

Treatment.  In  young  persons  the  tuberosity  should  he  fixed  in  place 
with  a  screw  by  open  operation,  making  an  incision  either  through  the 
deltoid  vertically,  in  its  mid-portion,  or  turning  forward  an  osteoplastic  flap 
of  the  posterior  part  of  the  deltoid  and  its  insertion  into  the  spine  and 
acromion  process  of  the  scapula  (Phemister)  ;  this  gives  good  exposure  and 
does  not  divide  any  muscles,  the  strip  of  bone  split  off  the  spine  of  the 
Bcapula  readily  uniting  if  sutured  hack  in  place. 

(/)  Complicated  [njdries  ajbotjt  the  Shoulder-joint.  Injuries  to 
the  main  vessels  and  nerves  may  occur  as  complications  of  the  fractures 


FRACTURE-DISLOCATIONS  279 

and  dislocations  of  this  region  ;  unfortunately  for  the  honour  of  surgery,  they 
also  occur  as  the  result  of  treatment  in  some  instances.  Should  the  axillary 
artery  be  torn  immediate  operation  is  needed,  the  subclavian  artery  com- 
pressed above  and  the  vessel  freely  exposed  :  if  possible  it  should  be  sutured, 
failing  this  the  two  ends  must  be  tied.  Injuries  to  the  brachial  plexus  are 
described  under  Nerve  Injuries. 

An  important  type  of  complicated  injury  is  when  a  dislocation  of  the 
shoulder- joint  occurs  associated  with  a  fracture  of  the  upper  end  of  the 
humerus  ;  such  conditions  are  often  only  diagnosable  with  certainty  by 
the  use  of  X-rays.  Mention  has  been  made  already  of  fractures  of  the 
great  tuberosity  associated  with  forward  dislocation,  the  treatment  being 
reduction  of  the  dislocation  by  manipulation  and  fixing  the  fragment  by 
operative  measures  or  rest  and  massage.  Fractures  of  the  surgical  and 
anatomical  neck  of  the  humerus  may  complicate  dislocation  of  the  shoulder, 
the  former  being  the  more  common.  Fracture  takes  place  after  dislocation, 
and  in  the  case  of  fracture  of  the  anatomical  neck  this  last  is  caught  against 
the  edge  of  the  glenoid,  the  deltoid  insertion  acts  as  a  fulcrum,  and  the 
continuation  of  the  force  causes  fracture. 

Diagnosis  is  usually  made  by  radiographs,  but  the  following  points  make 
this  possible  in  some  cases  from  ordinary  physical  examination.    (Fig.  89,  D.) 

(1)  The  head  is  not  in  the  glenoid  fossa,  nor  is  the  tuberosity  in  its 
position  below  the  tip  of  the  acromion,  but  the  dislocated  portion  is  some- 
where in  the  subcoracoid  region  ;  for  this  reason  a  straight  edge  can  touch 
both  the  acromial  tip  and  the  external  condyle  at  once — or,  in  other  words, 
Hamilton's  test  indicates  a  dislocation. 

(2)  In  spite  of  this  the  elbow  can  be  placed  close  to  the  side  when  the 
hand  rests  on  the  opposite  shoulder,  i.e.  Dugas's  test  points  to  the  absence 
of  dislocation.  The  conflicting  evidence  of  these  important  tests  will  render 
the  combination  of  a  fracture  with  a  dislocation  highly  probable. 

(3)  Crepitus  may  be  noted  on  examination. 

Treatment.  Traction  and  manipulation  will  almost  certainly  fail  to 
reduce  the  smaller  fragment  into  the  glenoid  fossa,  though  it  is  reported 
to  have  succeeded  on  one  or  more  occasions.  Waiting  till  the  fracture  unites 
is  waste  of  time  ;  therefore  the  site  of  lesion  should  be  exposed  by  the 
anterior  incision  between  deltoid  and  pectoralis  and  the  head  or  upper  frag- 
ment levered  back  into  its  position,  i.e.  the  dislocation  is  reduced.  Then  the 
fragments  of  the  fracture  are  adjusted  ;  in  most  instances  it  will,  no  doubt, 
be  best  to  fasten  these  with  a  plate.  No  pains  should  be  spared  in  securing 
reduction  of  the  head,  since  the  results  of  this  are  far  superior  to  those 
following  excision  of  the  upper  fragment.  Finally,  in  old,  feeble  persons 
the  condition  may  be  left  unreduced  and  attempt  made  to  form  a  new  joint 
by  massage  and  movements — provided  always  that  there  are  no  signs  of 
pressure  on  the  vessels  or  brachial  plexus,  in  which  case  operative  measures 
should  be  at  once  undertaken. 


A  TEXTBOOK  OF  SURGERY 


(4)  [njuries  in  the  Ai:m.  The  following  are  found  here:  Rupture 
of  tin-  biceps,  injuries  to  the  musculo-spiral  nerve,  fracture  of  the  shaft 
of  tlic  humerus. 

Anatomy.  The  humerus  lies  snugly  surrounded  by  muscles  but  is  readily 
ssible  to  deep  palpation  on  the  outer  side  belowthe  insertion  of  the 
deltoid  and  less  easily  on  the  inner  side  throughout  its  length.  Its  most  im- 
portant relation  is  the  musculo- 
spiral  nerve,  which  passes  round 
in  the  musculo-spiral  groove  un- 
der the  long  and  external  heads 
of  the  triceps  from  the  inner  to 
the  outer  side  of  the  arm  behind 
the  bone,  with  which  it  is  prac- 
t  ically  in  contact  for  some  inches 
in  the  middle  of  the  shaft,  and 
where  the  nerve  is  likely  to 
be  affected  in  fractures  of  the 
bone. 

(a)  Rupture  of  the  biceps 
usually  occurs  in  the  long  ten- 
don or  at  its  junction  with  the 
muscle,  and  is  caused  by  violent 
muscular  effort. 

Signs.  On  attempting  to 
flex  the  forearm  a  soft  fleshy 
swelling  appears  in  the  region 
of  the  biceps,  due  to  the  con- 
traction of  the  unstretched  belly 
of  the  muscle. 

Treatment.  If  strong  power 
of  flexion  is  needed  by  the 
patient  the  tendon  should  be 
exposed  and  sutured. 

(b)  Injuries  to  the  musculo-spiral  nerve  are  considered  with  those  of 
other  nerves. 

(c)  Fracture  of  the  shaft  of  the  humerus. 

This  may  take  place  at  any  point  along  the  shaft  and  may  be  transverse, 
oblique,  or  comminuted.  As  regards  displacement,  differences  are  noted 
according  as  the  lesion  is  above  or  below  the  insertion  of  the  deltoid,  though 
tin-  initial  violence  in  many  instances  determines  the  nature  of  the  displace- 
ment. 

(1)  Fracture  above  the  deltoid  insertion.  The  lower  end  of  the 
upper  fragment  is  pulled  inward  by  the  pectoral  and  latissimus  dorsi, 
while  the  lower  fragment  is  pulled  up  and  oul  by  the  deltoid  and  up  by 
the  biceps  and  triceps  :  tie'  deformity,  then,  is  an  inward  bowing  of  the 
bone. 


\'u:.    98.      a,   Deformity  in    fracture   .above    the 
deltoid    insertion,     b,   Positions    of   fraetures    in 
the  -haft  and  upper  end  of  the  humerus,    c,  De- 
formity in  fractures  below  the  deltoid  insertion. 


FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS 


281 


(2)  Fracture  below  the  deltoid  insertion.  The  lower  end  of  the  upper 
fragment  is  abducted  by  the  deltoid,  the  lower  fragment  being  pulled  up 
inside  this  by  the  biceps  and  triceps,  thus  causing  a  marked  bowing  outward 
of  the  bone. 

Diagnosis  is  easy  from  the  deformity  and  shortening,  the  abnormal 
mobility  in  the  shaft  and  the  crepitus. 

Union  is  more  often  by  fibrous  tissue 
in  this  situation  than  in  any  other  place 
amongst  long  bones. 

Treatment.  The  fragments  should  be 
reduced  by  traction  and  maintained  in 
position  : 

(1)  By  an  internal-angular  splint  from 
the  wrist  to  high  up  in  the  axilla,  the  arm 
being  surrounded  by  anterio  \  external  and 
posterior  straight  splints  or  a  piece  of 
Gooch  kettle-holder  splinting  cut  so  as  to 
surround  the  arm  on  all  aspects  except  the 
inner,  where  is  the  internal-angular  splint. 
These  splints  are  fastened  with  bands  of 
strapping  and  the  whole  slung  by  a  band 
age  from  the  neck  to  the  wrist  ;  thus  the 
weight  of  the  arm  and  splints  produces 
extension  of  the  humerus  and  prevents 
recurrence  of  deformity  by  spasm  of  the 
biceps  and  triceps. 

(2)  Should  the  position  not  be  good 
from  the  use  of  this  method,  especially 
in  fractures  below  the  deltoid,  where  there 
is  much  bowing  out  of  the  arm,  and  in 
muscular  subjects,  Middledorp's  triangle  may  be  used.  When  placed  on 
this  frame  the  hand  is  by  the  side  and  the  elbow  flexed  to  rather  more 
than  a  right  angle,  causing  abduction  of  the  arm  and  thus  bringing  the 
lower  fragment  into  line  with  the  already  abducted  upper  fragment.  If 
this  is  not  satisfactory  the  bone  should  be  exposed  by  incision  on  the  outer 
side  and  union  made  with  a  plate,'  care  being  taken  while  this  is  being  done 
to  protect  the  musculo-spiral  nerve  from  being  caught  between  the  frag- 
ments on  reduction.  We  have  known  this  happen  when  the  nerve  was  not 
seen  ;  therefore  if  operation  be  done  the  nerve  should  be  seen  while  the 
fracture  is  being  reduced,  that  this  accident  may  be  prevented.  Operative 
treatment  will  also  be  needed  for  non-union. 

In  most  cases  fair  union  will  be  present  in  a  month,  when  the  arm  may 
be  carried  in  a  sling.  The  patient  should  be  encouraged  to  move  the  fingers 
all  the  time  :  massage  can  be  commenced  when  the  splints  are  removed, 
but  passive  movements  of  the  elbow  are  to  be  made  with  care,  lest  movement 
take  place  at  the  fracture  and  not  at  the  joint. 


Fig.  99.  Treatment  of  fractures  of 
the  shaft  of  the  humerus  by  internal 
angular,  back,  front,  and  external 
arm  splints ;  the  fore-arm  being  slung 
at  the  wrist  so  that  the  weight  of  the 
arm  produces  extension. 


282 


A  TEXTBOOK  oK  SURGERY 


(5)    [njuries  about  the   Elbow-joint.     The  following  lesions  are 
described:    Fractures  and  separation  of  epiphyses  at  the  lower  end  of  the 

humerus,  myositis  ossificans,  dislocation  of   the  radius  and  ulna,  fractures 
of  the  upper  end  of  the  radius  and  ulna. 

Surgical  Anatomy.     The   following   bony   points  arc   important:    the 


Fio.  100. 


Middledorp's  triangle  for  fractures  of  the  humerus  where  the  upper 
fragment  is  abducted  by  the  deltoid. 


external  and  internal  condyles  of  the  humerus,  which  are  subcutaneous 
and  can  be  readily  traced  to  their  respective  supracondylar  ridges;  the 
olecranon  process  of  the  ulna.  It  should  be  noted  that  the  tip  of  the  ole- 
cranon lies  on  a  level  with  the  condyles  when  the  forearm  is  extended,  but 
when  this  is  flexed  the  olecranon  is  an  inch  below  the  condyles.  The  head 
ol  the  radius  can  be  fell  when  the  forearm  is  extended  below  the  external 
condyle  :  when  the  forearm  is  flexed  the  radial  head  is  in  front  of  the  external 
condyle  :  in  either  position  it  can  be  felt  to  rotate  on  pronating  and  supina- 
ting  the  forearm. 


SUPRACONDYLAR  FRACTURES 


283 


Two  movements  are  allowed  at  the  elbow- joint :  (a)  simple  flexion  and 
extension  at  the  trochlear-ulnar  joint  and  (b)  rotation  (here  called  pronation 
and  supination)  at  the  radio-ulnar  joint. 

It  will  be  further  noted  that  the  axis  of  the  forearm  is  not  in  the  same 
line  as  that  of  the  arm  but  is  slightly  abducted  from  this  to  the  amount  of 
ten  to  twenty  degrees,  the  angle  formed  being  known  as  the  carrying  angle. 
This  angle  is  often  altered  after  injuries  about  the  elbow- joint.  The  abduc- 
tion may  be  increased  "  cubitus 
valgus "  or  diminished  so  or 
changed  into  adduction  or  out- 
ward bowing,  "  cubitus  varus." 
Alteration  of  the  carrying  angle 
is  of  little  consequence  unless  of 
great  amount ;  far  more  impor  • 
tant  are  limitations  of  flexion 
or  extension  of  the  joint. 

(a)  Supracondylar  Frac- 
ture of  the  Humerus.  This 
fracture  is  usually  caused  by 
direct  violence  but  sometimes 
by  indirect :  the  lower  frag- 
ment is  displaced  backwards 
(rarely  forwards),  and  the  de- 
formity resembles  that  of  a  back- 
ward dislocation  of  the  radius 
and  ulna  at  the  elbow.  The  fol- 
lowing differences  are  present : 

(1)  The  length  of  the  hu- 
merus, measured  from  the 
deltoid  tubercle  to  the  lower 
end  of  the  supracondylar  ridge 
(or  external  condyle  when  pre- 
sent), is  diminished  in  fractures 
but  normal  in  dislocation ; 
whereas  the 

(2)  Length  of  the  forearm, 

measured  from  the  external  condyle  of  the  humerus  to  the  styloid  of  the 
radius,  is  unaltered  in  fracture  but  shortened  in  dislocation  backward. 

(3)  The  transverse  crease  of  the  elbow-joint  is  above  the  lower  end  of 
the  upper  fragment  in  dislocation  but  below  it  in  fracture. 

(4)  In  cases  of  fracture  the  fragments  can  be  readily  reduced  into  their 
normal  position  with  accompanying  crepitus  and  return  again  as  easily  to 
the  position  of  deformity ;  whereas  in  dislocations  the  deformity  is  reduced 
with  difficulty  but,  once  reduced,  retains  this  position. 

(5)  In  fractures  the  olecranon  retains  its  normal  position  to  the  condyles, 
while  in  dislocation  this  relation  is  altered. 


Fig.  101. 


J 

icture  of  the  lower  end  of  the  humerus 


(supracondylar)  with  forward  displacement  of  the 
lower  fragment  (an  unusual  position). 


284 


A  TEXTBOOK  OK  Sl'ROERY 


(b)  T-ob  Y-shaped  Fractures  of  the  Lower  End  of  the  Humerus 
cunsist  of  a  supracondylar  fracture  combined  with  a  vertical  splitting  of 
the  lower  fragment  which  passes  into  the  joint.  The  usual  cause  is  direct 
violence,  which  is  often  great,  aud  there  is  much  associated  bruising  and 
swelling.  The  deformity  resembles  that  of  supracondylar  fracture,  but 
in  addition  there  will  be  much  widening  of  the  elbow  and  the  condyles  can 
be  felt  to  move  on  each  other.  Owing  to  the  amount  of  effusion,  accurate 
diagnosis  may  often  be  difficult  without  radiographs. 

Treatment  <>[  Supracondylar  and  T-shaped  Fractures.  In  the  former 
variety  and  the  latter,  where  there  is  not  much  separation  of  the  condyles, 
the  fragments  can  as  a  rule  be  reduced  into  normal  position  by  flexing  the 


Fig.  102. 


Separation   of   lower   epiphysis    of    the    humerus    with    characteristic 
deformity. 


supinated  forearm  and  bandaging  the  arm  to  the  side  in  this  position.  The 
effect  of  flexing  the  forearm  is  not  only  to  reduce  the  backward  displacement 
but  also  the  hyper-extension  of  the  lower  fragment,  which  we  have  found 
to  be  the  chief  cause  of  disability  after  fractures  in  this  region.  Splints  are 
of  little  use  in  these  fractures  except  where  lateral  deformity  is  present, 
when  use  may  be  made  of  internal  or  external  angular  splints.  In  T-shaped 
fractures,  in  order  to  produce  proper  alignment  of  the  articular  surface  of 
the  lower  end  of  the  humerus,  open  operation  will  often  be  needed.  The 
seat  of  fracture  may  be  exposed  by  a  vertical  incision  splitting  the  triceps, 
and  the  fragments  united  by  screws  or  plates  ;  the  tri-radiate  plate,  which 
embraces  all  three  fragments,  will  be  useful  here. 

(c)  Fractures  of  the  Condyles  of  the  Humerus.  The  condyles  are 
usually  broken  off  by  direct  violence, but  the  external  condyle  has  been  broken 
off  by  the  force  of  a  fall  on  the  hand  transmitted  to  the  capitellum  along  the 
radius.  The  internal  epicondyle  may  be  broken  off  without  injury  to  the 
joint,  but  where  the  whole  of  either  condyle  is  broken  off  the  joint  is  inevi- 
tably involved. 


SEPARATION  OF  THE  LOWER  HUMERAL  EPIPHYSIS      285 

Signs.  Swelling  and  effusion  into  the  elbow- joint  with  mobility  of 
the  condyle  on  the  rest  of  the  humerus,  associated  with  crepitus,  will  be 
noted,  but  the  exact  line  of  fracture  can  only  be  detected  by  the  use  of 
X-rays. 

Treatment.  It  may  be  possible  to  reduce  the  deformity  by  full  flexion 
of  the  foreaim ;  should,  however,  this  method  fail,  as  is  likely,  recourse 
must  be  had  to  open  operation  and  the  fragments  fixed  by  pegs  or  screws. 
Should  the  epicondyle  be  broken  off  displacement  will  often  be  only  slight, 
and  it  will  suffice  to  sling  the  arm  for  a  few  days  and  use  massage  and 
movement  earlv.     Involvement  of  the  ulnar  nerve,  which  sometimes  com- 


Fig.  103.     Separation  of  lower  epiphysis  of  the  humerus  and  displacement  back- 
wards.    (Arcy.) 


plicates  fractures  of  the  epicondyle,  is  an  indication  for  open  operation  and 
preserving  the  nerve  from  further  injury.  When  put  up  in  the  flexed 
position  passive  movement  may  be  commenced  in  fourteen  days,  and 
consists  rather  in  further  flexion  than  extension  at  first :  massage  may  be 
employed  after  the  third  day  or  as  soon  as  the  wound  is  healed. 

Note.  Care  is  needed  in  the  employment  of  acute  flexion  for  these 
and  similar  injuries,  for  if  there  is  great  swelling  of  the  part  the  treatment 
may  interfere  with  the  blood-supply  and  cause  gangrene  or  ischsemic  con- 
tracture ;  therefore  the  flexion  in  cases  with  much  bruising  and  effusion 
should  be  moderate  for  three  days  and  gradually  increased  so  that  it  is  at 
an  acute  angle  in  seven  to  ten  days. 

(d)  Separation  of  the  Lower  Epiphysis  of  the  Humerus.  This  is  a 
very  common  accident  in  children  ;  indeed  in  our  experience  it  is  the 
commonest  injury  about  the  elbow-joint. 

Anatomy.  Ossification  of  this  epiphysis  appears  in  four  centres,  origina- 
ting in  the  capitellum  (two  years)  ;    this  centre  forms  the  capitellum  and 


286 


A  TEXTBOOK  OF  SURGERY 


pari  of  the  trochlea  ;  the  centres  for  the  real  oi  the  trochlea  and  externa] 
condyle  appear  at  eleven  and  twelve  respectively  ;  these  three  centres  fuse 
at  thirteen  and  join  the  shaft  at  seventeen  years.  The  centre,  for  the  internal 
condyle,  appears  at  five  and  joins  at  the  shaft  at  eighteen. 

In  children  under  six  the  epiphysis  is  usually  separated  as  a  whole; 
later  it  tends  to  bring  away  some  of  the  diaphysis  with  it  and  the  constituent 
parts  are  often  separated.  The  displacement  is  usually  backward,  com- 
bined with  lateral  deviation  in  some  instances.  Signs  resemble  those  of 
supracondyloid  or  T-shaped  Eracture,  but  the  lower  fragment  is  smaller 
and  the  age  of  the  patient  suggestive. 

Treatment.  As  with  other  fractures  of  the  lower  end  of  the  humerus, 
the  most  generally  useful  method   is  acute  flexion  of  the  supinated  forearm 

with  the  whole  arm  and  forearm  bandaged 
to  the  side.  Passive  movements  may  be 
commenced  in  ten  days.  Occasionally  open 
operation  will  be  needed,  especially  when 
the  displacement  is  lateral,  to  admit  of 
reduction  ;  fixing  with  screws  or  plates  is 
seldom  needed,  for  acute  flexion  will  as  a 
rule  maintain  proper  position  once  this 
has  been  attained. 

It  will  be  noted  that  acute  flexion  is 
the  main  plan  of  treatment  in  all  these 
fractures  at  the  lower  end  of  the  humerus. 
The  reason  is  that  the  lower  fragment  is 
usually  hyper-extended,  and  if  this  defor- 
mity is  allowed  to  persist  there  results 
great  loss  in  range  of  flexion  at  the  elbow, 
and  flexion  is  the  most  important  move- 
ment of  the  joint,  especially  to  angles  less 
than  a  right  angle. 

(e)  Injuries    to    the    Elbow- joint. 

The  following  are  described  :  (1)  Sprains  ; 

(■2)  dislocations  of   the  radius  and  ulna  from  the  humerus  or  each  other  ; 

(.'I)  fractures  of  the  upper  end  of  the  ulna;    (•!)  fractures   of  the   upper 

end  of  the  radius. 

(1)  Sprains  are  due  to  twists  or  wrenches  of  the  elbow  and  falls  on  the 
hand  insufficient  to  cause  dislocation  or  fracture. 

Signs.  Pain  and  impaired  movement,  especially  of  full  extension,  and 
effusion  into  the  joint,  best  detected  as  a  fluctuating  swelling  on  either  side 
of  the  olecranon. 

Treatment.  The  arm  should  be  slung  with  the  elbow  flexed  and  the 
joint  firmly  strapped  for  a  few  days  to  limit  effusion;  later,  massage  and 
passive  movements  should  restore  function  without  much  delay.  Prolonged 
disability  in  young  subjects,  especially  from  slight  injuries,  will  lead  to  the 
suspicion   of  oncoming  tuberculous  disease,   and  such  cases  need  careful 


FlG.    104.      Bandaging    the    acutely 

flexed  elbow  for  separation  of  the 

lower  epiphysis  <<i  the  humerus. 


DISLOCATIONS  OF  THE  ELBOW  287 

watching.  Of  course,  obscure  injuries  to  the  epiphyses  should  always 
be  excluded  by  the  use  of  X-rays. 

(2)  Dislocations  of  the  Elbow-joint.  These  occur  next  in  frequence 
to  those  of  the  shoulder  and  are  especially  common  in  children.  The 
following  dislocations  are  described  : 

A.     Of  both  bones.     (1)  Forward  ;    (2)  backward  ;    (3)  laterally. 


Fig.   105.     Dislocation  of  the  elbow  backwards  (there  is  some  associated  injury  of 

the  humeral  epiphysis. 

B.  Of  the  radius  only.  (1)  Forward ;  (2)  backward  ;  (3)  outward  ; 
(4)  "  pulled  elbow." 

C.  Of  the  ulna  only.     Backward. 

D.  Of  both  bones  but  in  opposite  directions,  the  ulna  going  back  and 
the  radius  forward. 

A  (1)  Displacement  of  both  bones  backward  is  the  commonest  dis- 
location of  the  elbow-joint.  It  is  usually  caused  by  a  fall  on  the  outstretched 
hand,  with  the  result  that  the  coronoid  process  is  forced  back  over  the 
trochlea  and  is  jammed  in  the  olecranon  fossa  of  the  humerus.  This  is 
especially  found  in  children  in  whom  the  coronoid  is  small  and  readily 
slips  backward.  This  catching  of  the  coronoid  is  the  main  obstacle  in 
reduction. 

Signs.  The  forearm  is  generally  semi-flexed  ;  there  is  a  large  projection 
behind  the  joint  caused  by  the  olecranon,  with  a  deep  hollow  above  it. 
The  deformity  is  far  greater  than  in  fractures  about  the  lower  end  of  the 
humerus,  and  the  greatly  impaired  mobility,  absence  of  crepitus,  and 
shortening  of  the  distance  between  the  styloid  of  the  radius  and  the  external 
condyle  of  the  humerus  compared  with  the  sound  side,  will  make  the  diagnosis 
clear. 


A  TEXTBOOK  OF  SURGERY 

Treatment.  It  is  necessary  to  unhitch  the  coronoid  process  from  the 
olecranon  fossa  and  make  it  pass  over  the  trochlea  to  its  normal  position. 
This  is  done  as  follows  : 

The  patient  being  seated,  the  Burgeon  places  his  knee  in  the  bend  of  the 
elbow  and  pulls  the  fore-arm  round  it  in  the  direction  of  flexion,  at  the  same 
time  pushing  the  knee  firmly  against  the  upper  end  of  the  forearm  and 
pulling  the  humerus  away  from  this  point  of  counter-extension.  In  this 
way  tin'  coronoid  is  disengaged  from  the  olecranon  fossa,  and  thus  reduction 


Fig.   106.     Backward  dislocation  at  the  elbow  (of  both  radius  and  ulna). 

is  effected  ;  additional  power  can  be  obtained  by  an  assistant  pushing  the 
olecranon  process  down  and  away  from  the  humerus.     (Fig.  107  A.) 

In  some  instances  the  coronoid  process  is  broken  off  in  this  accident, 
rendering  reduction  easy,  but  re-dislocation  speedily  takes  place ;  in  such 
cases  it  will  be  necessary  to  place  the  forearm  in  acute  flexion,  to  relax  the 
brachialis  anticus  which  is  pulling  the  coronoid  away  from  the  ulna — or 
operative  measures  may  be  attempted,  but  owing  to  the  small  size  of  the 
fragment  its  fixation  in  situ  with  a  peg  or  screw  is  not  an  easy  matter. 

A  (2)  Dislocation  of  both  bones  forward  is  due  to  falls  on  the  point 
of  the  elbow  ;  the  hook  of  the  olecranon  slips  over  the  trochlea  and  rests 
in  the  coronoid  fossa. 

Signs.  The  prominence  of  the  olecranon  is  lost,  the  condyles  of  the 
humerus  are  very  prominent,  and  the  forearm  is  acutely  flexed.    (Fig.  K)7  B.) 

Treatment.  The  forearm  must  be  still  more  acutely  flexed  and  the 
lower  end  dragged  forward  away  from  the  humerus  to  unhitch  the  olecranon 
process  from  the  coronoid  fossa,  when  extension  will  cause  reduction. 

\  (•'))  Lateral  dislocations  are  generally  partial  and  recognised  by  the 
position  of  the  bony  prominences;   they  are  reduced  by  manipulations. 

B  (I)  The  mosl  usual  dislocation  of  the  radius  alone  is  forward.  This 
dislocation  is  caused  by  falls  on  the  hand  with  the  forearm  pronated  ;  the 
orbicular  ligament  is  ruptured.     The  head  of  the  radius  comes  to  lie  in  front 


DISLOCATION  OF  THE  RADIUS 


289 


of  the  capitellum  and  above  the  latter,  where  it  can  be  felt  on  rotation  of 
the  forearm,  while  there  is  a  hollow  below  the  external  condyle.  The 
forearm  is  semiflexed  and  pronated.  Supination  and  flexion  of  the  forearm 
are  greatly  interfered  with. 

Treatment.  Traction  of  the  semiflexed  forearm,  with  rotation  of  the 
wrist  and  pressure  over  the  head  of  the  bone,  may  suffice  for  reduction  in 
recent  cases,  but  as  the  orbicular  ligament  is  torn  re-dislocation  often  results, 
and  if  the  case  is  of  any  standing  very  likely  the  socket  will  be  overgrown  with 
fibrous  tissue  ;  hence  operative  measures  are  often  needed  both  to  enable 
reduction  to  be  accomplished  and  to  prevent  recurrence. 

The  head  is  exposed  by  an  incision  along  the  anterior  edge  of  the  supinator 
longus  muscle  and  an  attempt  made  to  reform  the  socket  and  close  this 


Fig.   1**7.     A.  Reducing  a  backward  dislocation  of  the  elbow  by  traction  around 
the  surgeon's  knee,     (a  I  indicates  an  assistant's  hand  pushing  on  the  olecranon  where 
more  force  is  needed.     B,  Direction  of  forces  required  to  reduce  a  forward  disloca- 
tion of  the  elbow. 


round  the  radial  head.  Should  such  measures  fail,  excision  of  the  head  will 
be  needed. 

A  common  complication  of  this  dislocation  is  a  fracture  of  the  upper 
third  of  the  ulna  with  a  bowing-in  of  this  bone  toward  the  radius. 

The  dislocation  is  often  overlooked  in  this  combination,  and  hence 
examination  should  be  always  made  for  such  a  condition  in  fractures  of  the 
ulna  in  its  upper  part,  The  dislocation  is  usually  of  more  importance 
than  the  fracture  and  should  always  be  reduced,  by  open  operation  if 
accessary  ;   the  ulnar  deformity,  unless  great,  will  need  only  rest  on  splints. 

B  (2)  In  outward  dislocation,  which  is  rare,  the  head  rests  on  the  outer 
side  of  tlic  external  condyle. 

B  (3)  In  backward  dislocation  the  radial  head  is  behind  the  external 
condyle,  where  it  can  be  felt,  and  causes  little  trouble  if  unreduced. 

B  (1)  A  condition  of  importance  from  its  frequency  is  subluxation  of 

the  head  of  the  radius  (Hutchinson),  popularly  known,  from  the  manner 

in  which  it  is  produced,  as  "  pulled  elbow.""     This  lesion  is  caused  by  giving 

a  sudden  violent  jerk  to  a  child's  arm  when  holding  it  by  the  wrist.     The 

i  19 


\  TEXTBOOK  OF  SURGERY 

result  is  thai  the  head  is  partly  luxated  from  the  orbicular  ligament,  and 
a  fold  of  Bynovial  membrane  is  nipped  between  the  head  and  the  capitellum. 
Tin'  arm  is  found  to  be  semiflexed,  pronated,  and  painful.  The  condition 
is  quickly  relieved  by  fully  flexing  the  forearm  and  thou  pronating  and 

supinating  (rotation)  while  in  this  position  ;  when  extended  the  pain  and 
disability  will  have  disappeared. 

C.  The  ulna  is  rarely  dislocated  alone  owing  to  the  strength  of  its 
connections  with  the  radius,  and  when  so  displaced  always  travels  back- 
wards. There  is  in  such  lesions  a  great  projection  of  the  olecranon  back- 
wards, as  in  dislocation  of  both  hones,  hut  the  head  of  tin1  radius  can  be 
felt  in  its  place  in  front  of  the  capitellum.  Reduction  is  performed  by  a 
similar  manoeuvre  to  that  employed  when  both  bones  are  dislocated  back- 
ward. 

D.  This  is  a  variation  of  the  last  form,  the  radius  in  addition  being 
dislocated  forwards,  and  there  is  naturally  great  deformity. 

Complications.  Not  infrequently  dislocations  of  the  elbow-joint  are 
combined  with  fractures  or  separations  of  the  epiphyses  in  the  neighbour- 
hood, so  that  the  complexity  of  the  deformity,  together  with  the  swelling, 
renders  diagnosis,  apart  from  the  use  of  X-rays,  an  impossibility. 

In  such  cases  tin-  advisability  of  open  operation  will  always  have  to  be 
considered,  and  usually  adopted,  in  older  to  avoid  the  trouble  likely  to 
arise  later  from  a  bad  position  of  the  joint  surfaces  and  inconvenient 
adhesions. 

(3)  Fractures  of  the  Upper  End  of  the  Ulna  comprise  (a)  those  of 
the  olecranon.  (6)  those  of  the  coronoid  process. 

(a)  The  olecranon  is  usually  fractured  by  falls  on  the  point  of  the  elbow. 
The  line  of  separation  may  pass  through  the  base  of  the  process  or  nearer 
the  tip.  and  it  is  in  the  latter  case  that  we  find  separation  more  marked. 

Signs.  There  is  considerable  effusion  into  the  joint,  voluntary  exten- 
sion of  the  forearm  is  painful  and  often  greatly  impaired.  The  tip  of  the 
olecranon  can  be  moved  on  the  shaft  of  the  ulna  ;  if  much  separation  is 
present  a  groove  can  be  felt  between  the  smaller  fragment  and  the  shift. 
ainl  perhaps  crepitus  elicited. 

Treatment.  Where  there  is  no  separation  it  will  suffice  to  sling  the 
slightly  flexed  forearm  and  practise  early  massage  and  movements.  Should 
-■■pa ration  be  present,  it  is  impossible  to  secure  bony  union  by  any  method 
of  splinting  owing  to  the  rotation  of  the  smaller  fragment  and  the  inter- 
position of  fascia  ;  consequently  open  operation  is  indicated  in  young 
active  persons.  We  find  that  the  simplest  plan  is  to  drive  a  screw  through 
the  small  fragment  into  the  cancellous  tissue  at  the  end  of  the  ulna — a 
simpler  process  than  passing  a  wire  and  quite  as  effective.  Where  open 
operation,  is  not  indicated  it  is  bad  practice  to  try  to  attain  apposition  of 
the  fragments  by  extending  the  elbow  on  a  straight  splint  and  allowing  the 
arm  to  hang  vertically,  as  the  confined  position  and  congestion  arising  are 
very  likely  to  cause  permanenl  stiffness  of  the  fingers  and  wrist. 

It  should  be  noted  that   fibrous  union  often  gives  a  fairly  strong  and 


FRACTURES  OF  THE  UPPER  RADII'S 


291 


useful  joint,  though  not  so  good  as  a  satisfactory  open  operation,  which  is 
therefore  advisable  in  those  who  need  a  strong  limb  for  business  or  sport. 

(b)  Fracture  of  the  coronoid  process  hardly  ever  occurs  except  as  a 
complication  of  dislocation  backwards  of  the  ulna.  The  diagnosis  is  made 
from  the  dislocation  readily  recurring  after 
reduction  and  by  radiographic  investiga- 
tion. 

Treatment.  The  arm,  after  reduction  of 
the  dislocation,  should  be  put  up  acutely 
flexed  at  the  elbow  for  three  weeks,  and 
failing  to  secure  union  thus,  an  attempt 
should  be  made  to  fix  the  fragment  by 
open  operation,  which  may  not  be  an  easy 
matter  owing  to  the  smallness  of  the  frag- 
ment and  the  depth  of  the  ulna  at  this 
point. 

(c)  Separation  of  the  upper  epiphysis 
of  the  ulna.  It  seems  doubtful  if  this 
ever  occurs.  But  it  is  important  in  diag- 
nosis to  remember  that  the  epiphysis  is  a 
small  scale  at  the  end  of  the  ulna  in  which 
ossification  appears  at  about  ten  years, 
and  till  this  is  joined  with  the  rest  of  the 
olecranon  at  eighteen  may  be  mistaken  bv 
the  unwary  for  a  fracture  of  the  olecranon 
when  examining  a  radiogram  of  an  injury 
about  the  elbow. 

(4)  Of  fractures  at  the  upper  end  of 
the  radius  we  find  (a)  those  of  the  head, 
(b)  those  of  the  neck. 

(a)  The  head  of  the  radius  may  be 
fractured  by  direct  violence,  one  or  more 
fragments  being  broken  off.  Accurate  diagnosis  apart  from  X-rays  is  not 
possible,  but  swelling  in  this  region  and  crepitus  on  rotating  the  forearm 
may  give  a  clue  as  to  the  nature  of  the  injury. 

Treatment.  Open  operation,  removing  loose  fragments  and  smoothing  off 
rough  surfaces,  is  the  best  line  to  adopt. 

(6)  In  children  the  head  of  the  radius  may  be  broken  off  at  the  epiphyseal 
line,  where  union  with  the  shaft  takes  place  at  eighteen  years.  Good  union 
results  if  the  arm  is  put  up  in  acute  flexion. 

In  adults  fracture  may  take  place  between  the  orbicular  ligament  and 
the  insertion  of  the  biceps-tendon. 

Signs.  The  head  of  the  radius  fails  to  rotate  with  the  forearm  and  the 
lower  fragment  is  drawn  up  by  the  biceps  to  form  a  projection  in  front, 
in  the  anticubital  fossa. 

As  in  the  separation  of  the  epiphysis,  the  forearm  should  be  placed  in 


Fig.  108. 


Fractured  olecranon  secured 
by  a  screw. 


292 


A  TEXTBOOK   OK  SIROERY 


full  supination  and  flexion  to  relax  the  biceps;  massage  may  1>«>  performed 
from  the  outset,  passive  movements  in  tin-  direction  of  flexion  and  extension 

in  Fourteen  days,  bul  rotation  not  till  ten  days  later. 

(5)  Myositis  ossificans.  The  region  of  the  elbow  is  one  of  the  places 
where  ossification  of  muscle  is  prone  to  arise  after  injuries,  whether  from 
dislocations  of  the  forearm  or  fracture  in  this  region  (more  often  from  the 
former),  and  usually  affect  the  brachialis  anticus  near  its  insertion. 

Diagnosis  is  made  from  finding  a  hard  mass  in  the  anticubital  fossa 
arising  sonic  weeks  or  months  after  such  injuries,  which  is  found  not  to  be 
due  to  any  displacement  of  the  bony  structures  and  by 
X-ray  examination. 

Treatment  is  unsatisfactory,  excision  of  the  mass 
being  usually  followed  by  recurrence :  X-rays  are 
worth  a  trial. 

6.    FRACTURES   OF   THE   FOREARM 

Anatomy.    The  ulna  is  subcutaneous   throughout 
its  length   and    readily   palpated  :     the   shaft   of   the 
radius  is  covered  with  muscles   and  felt 
with  difficulty,  except  towards  the  lower 
end,  but  by  rotating  the  hand  at  the 
wrist   and   palpating   the   head    of   the 
radius  one  can  make  out  whether  frac- 
ture has  occurred  in  its  length  ;    but  to 
settle  whether  the  lesion  is  below  or  above  the  inser- 
tion  of    the   pronator   radii   teres    X-rays    are    often 
needed. 

(a)  Fracture   of   the   Shafts,  of  the   Radius, 

and   Ulna   together.     The  radius  and  ulna  may  be 

fractured   separately   but    more    often    together,    and 

most  usually  in  the  middle  of  their  shafts,  though  not 

uncommonly  towards  their  lower  ends.     There  is  a  tendency  for  all  four 

fragments  to  approach  each  other  in  the  mid-line  owing  to  the  pulling 

inwards  of  the  radius  by  its  pronator  muscles. 

Diagnosis  is  made  readily  from  the  abnormal  mobility,  crepitus,  and 
alteration  in  the  contour  of  the  bones,  especially  of  the  ulna. 

Treatment.  To  prevent  cross-union  after  reduction  the  forearm  should 
be  placed  in  the  position  midway  between  pronation  and  supination,  as  in 
this  position  the  distance  between  the  bones  is  greatest.     (Fig.  109.) 

An  internal  angular  and  external  splint  for  the  forearm  will  generally  suffice, 
but  should  the  fracture  of  the  radius  be  above  the  insertion  of  the  pronator 
radii  teres  the  forearm  should  be  fully  supinated  (Fig.  1 10)  :  the  splints  must 
be  sufficiently  wide  to  prevent  the  bandage  from  drawing  the  fragments 
together  and  causing  cross-union.  Care  must  also  be  taken  that  the  splints 
do  not  lit  too  tightly,  since  this  is  the  place  where  ischemic  contracture  is 
most  likely  to  develop.     Should  the  position  of  the  bones  not  be  thoroughly 


Fig.  109.    Internal  an- 
gular    and     external 

splints      applied      for 

fractures  of  the  radius 

and  ulna. 


FRACTURES  OF  THE  RADIUS  AND  ULNA 


293 


satisfactory  with  splinting,  they  should  be  exposed  by  open  operation  and 
fixed  with  plates.  The  ulna  being  readily  reached  at  any  point  along  its 
subcutaneous  border,  the  radius  may  be  attacked  by  an  incision  along  the 
anterior  border  of  the  supinator  longus.  Massage  should  be  commenced  in 
a  week,  the  forearm  remaining  on  the  internal  angular  splint ;  passive 
movements  of  flexion  and  extension  may  be  cautiously  commenced  at  the 
elbow  in  fourteen  days,  but  pronation 
and  supination  not  for  at  least  three 
weeks. 

(b)  Fractures  of  the  Shaft  of  the 
Ulna  alone.  This  is  not  a  common  con- 
dition but  may  occur  in  any  part  of  the 
shaft.  In  the  upper  third,  as  has  been 
mentioned,  it  is  often  combined  with 
forward  dislocation  of  the  head  of  the 
radius.  Owing  to  the  subcutaneous  posi- 
tion of  the  ulna,  these  fractures  are 
readily  recognized. 

Treatment  is  as  for  fractures  of  both 
bones,  displacement  being  slight  in  most 
instances  ;  should  displacement  be  gross, 
open  operation  will  often  be  the  best 
line  of  treatment. 

(c)  Fractures  of  the  Shaft  of  the 
Radius  alone.  These  are  due  to  falls 
on  the  outstretched  hand,  and  may  occur 
(1)  above  or  (2)  below  the  insertion  of 
the  pronator  radii  teres,  in  the  middle  of 
the  outward  curve  of  the  radius. 

(1)  In  this  position  the  upper  frag- 
ment   is    supinated    by   the    biceps    and 

supinator  brevis,  so  that  to  avoid  loss  of  supination  it  is  necessary  to  put 
up  the  forearm  fully  supinated  in  order  that  the  lower  fragment  may  be 
supinated  as  well.  This  is  managed  by  supinating  and  flexing  the  forearm 
to  a  right  angle  and  placing  it  on  a  posterior  angular  "  gutter  "  splint, 
which  steadies  the  elbow,  with  an  anterior  straight  splint  on  the  flexor 
surface  from  the  elbow  to  the  wrist.  Should  this  method  prove  unsatis- 
factory, as  is  likely  in  muscular  forearms,  it  will  be  advisable  to  cut  down  and 
plate  the  fracture,  since  loss  of  supination  is  a  serious  disability.    (Fig.  110.) 

(2)  In  fractures  of  the  radius  below  the  pronator  insertion  there  is 
usually  little  displacement,  both  fragments  being  in  the  mid  prone-supine 
position.  The  fragments  are  readily  controlled  by  an  internal  angular  and 
external  straight  splints  ;  massage  and  movements  are  performed  as  in 
fractures  of  both  bones. 


Fig.  1 10.  Fracture  of  the  radius  above 
the  insertion  of  the  pronator  radii  teres  ; 
method  of  splinting  with  posterior  gut- 
ter and  anterior  forearm  splints  to 
maintain  supination. 


294 


A  TEXTBOOK  OF  SURGERY 


7.    INJURIES   ABOUT  THE  WRIST 
These  include:    (a)  Sprains;    (6)  fractures  of  the   lower  end  of  the 

radius  ;  (c)  fractures  of  the  lower  end  of  the  ulna  :  (</)  dislocations  of  the 
lower  radio-ulnai  joint  ;  (e)  dislocations  of  the  radiocarpal  (wrist)  joint; 
(/')  fractures  of  the  carpal  bones;   (</)  dislocations  of  the  carpal  1  ones. 

Surgical  Anatomy.  The  lower  end  of  the  radius  is  almost  entirely 
subcutaneous  and  can  be  readily  palpated.  The  head  of  the  ulna  can  be 
Been  and  felt  as  a  projection  on  the  back  of  the  pronated  wrist,  but  its 

styloid  process  cannot  be  seen  in 
any  position  and  is  only  felt  by 
palpating  deeply.  It  should  be 
noted  thai  the  styloid  process  of 
the  radius  is  half  an  inch  lower 
than  that  of  the  ulna  and  some- 
what in  front  of  this  point.  The 
lowest  skin-crease  in  front  of  the 
wrist  is  opposite  the  neck  of  the 
os-magnum  and  three-quarters  of 
an  inch  below  the  radiocarpal  joint. 
The  lower  epiphysis  of  the  radius 
appears  at  two  and  that  of  the 
ulna  at  seven  years,  while  both 
unite  with  their  shafts  at  twenty- 
two. 

(a)  Sprains  are   chiefly  of  im- 
portance from  leading  to  errors  of 
diagnosis.      Thus    impacted    frac- 
tures   of    the    lower    end    of    the 
radius  or  separations   of   the  epi- 
physis may  be  taken  for  sprains 
and     a    too    favourable    prognosis 
given  ;    fortunately,  treating  frac- 
tures in  this  position  as  sprains  will  usually  give  good  results.     It  should 
also  be  noted  that  neglected   sprains    may  lead   to  the  development   of 
tuberculosis  of  the  wrist. 

Diagnosis.  An  effusion  into  the  wrist  joint  can  easily  be  felt  both  in 
front  and  especially  behind  the  joint. 

The  styloid  processes  of  the  radius  and  ulna  will  occupy  their  normal 
positions,  but  as  the  displacement  of  the  radius  may  be  very  slight  in 
impacted  fractures,  it  is  best  to  take  a  radiograph  in  all  doubtful  cases. 

Treatment.  Firm  pressure  around  the  wrist  by  means  of  strapping,  with 
active  movements  of  the  fingers  and  massage  of  the  forearm;  after  ten 
days  massage  and  movements  of  the  wrist  as  well. 

(b)  Fractures  of  the  Lower  End  of  the  Radius.  These  are  among 
the  commonest  of  fractures,  especially  notable  in  old  women.     In  persons 


1 


ri,..  ill.  (ollcs'.-  fracture  oi  the  lower  end 
of  the  radius  (antero-posterior  view).  Note 
that  the  radial  styloid  (arrows)  is  proximal  to 
the  ulnar  styloid  instead   "t   being  half-inch 

distal  to  it. 


COLLES'S  FRACTURE 


295 


under  twenty  separation  of  the  lower  epiphysis  may  take  the  place  of 
fracture.  These  fractures  usually  result  from  falls  on  the  outstretched 
pronated  hand,  which  in  adults  are  more  apt  to  produce  injuries  to  the 
elbow,  humerus,  shoulder,  or  clavicle. 

Displacement.  When  broken  in  this  manner  the  radius  gives  way  at 
various  points  within  two  inches  of  its  lower  end  (Colles's  fracture)  and  the 
following  displacement  occurs.  The  lower  fragment  is  displaced  backward 
to  a  varying  degree,  forming  a  projection  on  the  back  of  the  wrist  and 
carrying  with  it  the  hand,  altering  the  alignment  of  the  latter  and  giving 
the  well-known  wk  dinner-fork  deformity."  This  fragment  is  also  displaced 
upwards,  and  the  lower  end  of  the  upper  fragment  or  shaft  may  be  impacted 


Fig.  112.     Carr's  splint  for  Colles"s  fracture,  and  its  application. 


in  the  lower  fragment.  In  addition  there  is  a  rotation  of  the  lower  fragment, 
so  that  the  articular  surface,  instead  of  being  at  right  angles  to  the  axis  of 
the  radius,  looks  partly  to  its  dorsal  or  extensor  surface.  Where  the  injury 
is  severe  the  triangular  fibro-cartilage  uniting  the  lower  end  of  the  radius 
to  the  styloid  process  of  the  ulna  may  be  torn,  or  more  often  the  styloid  of 
the  ulna  is  broken  off  ;  this  latter  complication  is  found  in  about  one-third 
or  more  of  all  cases. 

Diagnosis.  In  cases  with  marked  deformity  this  is  easy.  The  radial 
abduction  and  backward  displacement  of  the  hand  a  short  distance  above 
the  wrist,  the  projection  of  the  lower  end  of  the  ulna  (due  to  the  abduction), 
and  the  whole  "  dinner- fork  "  deformity  make  this  fracture  a  picture  not 
easily  mistaken.  In  cases  where  the  displacement  is  chiefly  upward  and 
but  slight,  as  often  happens  where  impaction  is  present,  care  is  needed  ; 
here  the  position  of  the  styloid  processes  of  the  radius  and  ulna  must  be 
compared  on  the  two  sides,  and  often  X-rays  are  of  great  help  to  ascertain 
if  only  a  sprain  is  present.     Backward  dislocation  of  the  carpus  at  the  radio- 


\  TEXTBOOK  OF  SURGERY 

carpal  joint  is  distinguished  by  the  much  greater  deformity  and  by  the 
Btyloid  processes  being  in  their  normal  position. 

Treatment.  Reduction  of  the  deformity  Bhould  always  be  attempted  by 
pulling  the  hand  over  towards  the  ulna  (adduction),  flexing  the  wrist,  and 
pushing  the  displaced  fragment  into  position  with  the  thumb  of  the  surgeon's 
hand,  which  is  exerting  counter-extension  on  the  forearm.  Complete 
reduction  is  not  always  possible  (owing  to  the  jagged  ends  of  the  fragments) 
and  is  likely  partially  to  recur  if  attained,  whatever  method  of  splinting  be 
employed.  Fortunately,  good  results  obtain  even  with  persistenl  deformity 
if  this  be  not  too  great.  To  maintain  reduction  we  find  Carr's  splint  most 
satisfactory.  This  consists  of  a  straight  anterior  splint  hollowed  at  its 
carpal  end  to  receive  the  thenar  eminence  and  having  a  cross:bar  at  this 
end  set  obliquely  for  the  hand  to  grasp,  in  such  a  way  that  this  produces 
ulnar  adduction  of  the  wrist.  The  forearm  and  wrist  to  the  ends  of  the  meta- 
carpals are  lightly  bandaged  on  this  splint,  leaving  the  lingers  free  ;  there 
should  he  plenty  of  padding  over  the  posterior  surface  of  the  wrist,  and  we 
consider  a  posterior  splint  inadvisable  as  being  likely  to  cause  adhesions  of 
the  extensor  tendons.  Massage  can  be  carried  out  on  the  splint  from  the 
third  day,  together  with  active  and  passive  movements  of  the  fingers; 
after  a  week  passive  movements  of  the  wrist  can  be  cautiously  commenced  : 
in  two  or  three  weeks  the  splint  is  omitted  and  stronger  active  movements 
indulged  in,  including  flexion  and  extension  of  the  wrist,  grasping,  and 
pronation  and  supination,  all  against  resistance. 

A  variety  of  this  fracture  takes  place  when  in  starting  a  motor-car  the 
handle  is  driven  violently  against  the  thenar  eminence  by  a  "  back-fire  " 
[chauffeur's  fracture).  In  this  type  the  styloid  process  of  the  radius  is 
broken  off  obliquely  into  the  joint;  there  is  little  deformity  but  much 
sti tl'i iess  and  disability.     The  treatment  is  as  for  Colles's  fracture. 

It  should  be  mentioned  that  cases  of  Colles's  fracture  with  but  little 
displacement  may  be  treated  by  slinging  the  forearm,  without  splinting, 
and  using  massage  and  movements  as  described  above.  This  is  perhaps 
the  best  situation  tor  the  use  of  the  massage  method  in  its  entirety. 

paration  of  the  lower  epiphysis  may  take  the  place  of  Colles's  fracture 
in  young  subjects  ;   the  deformity  is  similar  but  the  more  marked,  the  lower 
end  of  the  diaphysis  forming  a  sharp  projection  forwards  which  may  injure 
els  or  nerves  or  even  become  compound. 

Treatment  is  similar  to  that  for  Colles's  fracture,  but  special  care  is 
needed  to  reduce  the  epiphysis  completely,  and  if  this  is  not  possible  by 
manipulation  an  incision  should  be  made  and  tin'  fragmenl  levered  into 
place.  Occasionally  diminished  growth  will  follow  this  injury,  leading  to 
marked  radial  abduction  of  the  hand,  which  can  only  be  remedied  by  removal 
of  part  of  the  ulna. 

Fracture  of  the  Styloid  Process  of  the  Ulna,  or  separation  of 
the  lower  epiphysis  (which  includes  the  head),  rarely  occurs  except  associated 
with  Colles's  fracture,  in  which  case  it  is  the  styloid  which  is  broken  off. 
'1  his  complication  of  the  former  fracture  is  often  missed  without  the  help 


DISLOCATIONS  OF  THE  WRIST 


297 


of  X-rays,  and  always  implies  a  more  severe  lesion  and  a  worse  prognosis. 
'J  he  treatment  is  as  for  Colles's  fracture. 

(d)  Dislocation  of  the  Loaver  Radio-ulnar  Articulation.  The 
radius  may  be  displaced  forwards  or  backwards  on  the  lower  end  of  the  ulna. 
the  former  being  the  more  common  lesion  ;  there  may  be  laceration  of  the 
intra -articular  fibro-cartilage. 

Diagnosis  is  not  difficult.  In  both  varieties  the  wrist  is  curiously 
narrowed  :  when  the  radius  is  displaced  forwards  the  head  of  the  ulna 
makes  a  marked  projection 
behind,  while  in  the  converse 
dislocation  there  will  be  noted 
a  hollow  over  the  head  of  the 
ulna,  made  by  the  backward 
displacement  Qf  the  radius. 

Treatment.  Reduction  is 
achieved  by  traction  on  the 
hand,  and  if  the  radius  is 
forward  pushing  it  back  and 
the  ulna  forward,  i.e.  supin 
ating  the  forearm,  while  in 
the  other  variety  the  hand  is 
pronated.  with  traction. 

(e)  Dislocation  of  the 
Radio-carpal  Joint.  The 
carpus  may  be  dislocated 
forward  or  backward  on  the 
lower  end  of  the  radius — the 
latter  being  the  more  com 
mon  lesion,  though  both  are 
rare.  The  dislocation  back- 
ward is  distinguished  from 
Colles's     fracture      by      the 

greater  deformity  present  and  the  styloid  processes  being  in  their  normal 
position. 

Treatment.  Reduction  is  easy  by  traction  on  the  hand  and  pressing  the 
carpus  back  into  its  position.  Firm  pressure  by  bandaging  over  wool, 
carrying  the  arm  in  a  sling,  and  massaging  from  the  third  day.  will  complete 
the  cure. 

(/)  Fractures  of  the  Carpal  Bones.  These  are  not  common,  but 
the  use  of  X-rays  shows  that  they  are  by  no  means  so  rare  as  was  formerly 
believed.  The  best-known  individual  fracture  is  that  of  the  carpal  scaphoid, 
and  results  from  blows  with  the  fist  or  falls  on  the  outstretched  hand.  The 
line  of  fracture  is  between  the  radial  and  trapezoidal  surfaces,  i.e.  in  the 
narrowest  part  of  the  bone. 

Diagnosis.  The  condition  resembles  a  sprain  of  the  wrist,  but  there  is 
more  disability  and  the  swelling  is  on  the  radial  side  only,  while  the  styloid 


V\r,.     113. 


Fracture  of  the  carpal  scaphoid 
(radiogram). 


{Kindly  lent  by  Dr.  Gilbzrt  Scott.) 


\  TEXTBOOK  OF  SURGERY 


processes  are  in  Qormal  position.  There  Is  marked  tenderness  below  the 
styloid  process  of  the  radius  and  extension  of  the  wrist  is  very  painful, 
flexion  less  so;  crepitus  may  be  detected,  lni<  the  diagnosis  is  seldom 
conclusive  without  the  use  of  X-rays  to  both  wrists. 

Treatment.  It  is  generally  advised  to  put  up  the  wrist  in  a  position  of 
radial  abduction  and  extension  in  a  poroplastic  splint  reaching  from  the 
middle  of  the  forearm  to  the  ends  of  the  metacarpals  for  two  to  three  weeks. 
after  which  massage  and  movements  are  indicated  :  where  there  is  severe 
displacement  the  fragmenl   displaced  is  best  removed. 

(<l)  Dislocation  of  Individual  Carpal  Bones.  The  best-known 
example  of  this  is  a  backward  displacement  of  the  os  magnum,  produced  by 


Fig. 


114.     Fracture  of  metacarpal  of  the  ring-finger  causing  flattening  of  the  corre- 
sponding  knuckle  shown  in  A  (compare  with  1>.  which  is  round). 


strong  over-flexion  of  the  wrist  and  detected  by  the  presence  of  a  lump 
on  the  back  of  the  wrist  most  marked  on  flexion. 

11  the  bone  cannot  be  reduced  by  manipulation  it  should  be  explored  by 
open  operation,  and  if  still  irreducible,  removed. 


8.     INJURIES  OF   THE   HAND  AND  FINGERS 

These- include  fractures  and  dislocations  of  the  metacarpals,  fractures 
and  dislocations  of  the  phalanges. 

(a)  Fractures  of  the  metacarpals  occur  (1)  at  the  base,  (2)  in  the  shaft. 

(1)  This  fracture  usually  occurs  in  the  metacarpal  of  the  thumb,  but 
also  rarely  in  that  of  the  little  finger,  never  in  the  others.  In  the  thumb  it 
consists  of  an  oblique  fracture  extending  from  the  front  a  <piarter  of  an  inch 
above  the  base,  back  into  the  joint  (Bennett),  and  is  generally  caused  by  an 
ill-directed,  swinging  Mow  with  the  fist. 

Signs.  Their  is  pain  and  swelling  of  the  carpo-metacarpal  joint  and 
usually  subluxation  backwards;  indeed  this  lesion  is  often  taken  lor  a 
pure  dislocation  backwards  of  this  joint. 


FRAfTTTlES  OF  THE  METACARPALS  200 

Treatment.  The  thumb  should  be  put  up  in  a  position  of  abduction 
(which  reduces  the  deformity),  either  on  a  poroplastic  splint  or  divided 
plaster-case,  for  ten  days,  after  which  massage  may  be  of  use,  but  passive 
movements  should  not  be  commenced  for  at  least  three  weeks  or  dislocation 
will  recur  with  separation  of  the  fragments. 

(2)  Fractures  of  the  shaft  of  the  metacarpals  (punch-fractures)  occur 
in  any  of  these  about  their  middle,  but  most  usually  in  the  second  or  third. 
The  most  fertile  source  of  this  lesion  is  from  punching  some  hard  object 
such  as  the  solid  occiput  or  forehead  of  an  opponent,  instead  of  his  softer 
nose  or  more  yielding  jaw. 

Signs.  There  will  be  pain  and  swelling  at  the  seat  of  fracture,  abnormal 
mobility  detected  on  grasping  the  two  ends  of  the  bone  and  trying  to  bend 


Fig.  115.     Backward  dislocation  of  thumb  at  the  metacarpophalangeal  joint  with 
jamming  of  the  glenoid  ligament. 

it,  sometimes  also  crepitus  ;  but  the  most  obvious  sign  is  the  dropping  back 
of  the  knuckle  of  the  affected  digit  so  as  to  be  out  of  the  line  of  the  other 
knuckles.     (Fig.  119.) 

Treatment.  A  rolled  up  three-inch  bandage  of  two  inches  in  diameter 
should  be  placed  in  the  palm  of  the  hand  and  the  fingers,  including  the 
damaged  one,  flexed  over  this,  keeping  them  in  position  wTith  strapping. 
This  will  effect  extension  of  the  broken  metacarpal  and  usually  reduction 
as  well,  shown  by  the  knuckle  coming  into  its  proper  alignment.  The 
position  is  maintained  for  fourteen  days,  after  which  massage  and  movements 
are  employed. 

(6)  Dislocation  of  the  Metacarpal  Boxes.  The  metacarpal  of  the 
thumb  may  be  dislocated  back  on  the  trapezium  apart  from  fracture  of 
the  base,  as  in  Bennett's  fracture  ;  the  displacement  and  treatment  are 
identical. 

Dislocation  of  the  metacarpophalangeal  joint  occurs  usually  in  the 
thumb,  but  may  also  happen  at  any  of  the  metacarpophalangeal 
joints. 


A  TEXTBOOK  OF  SURGERY 


Displacement  is  nearly  always  backward  and  is  found  in  t\\<>  forms  : 
(a)  The  proximal  phalanx  is  greatly  hyper-extended  and  projects  back 

nearly  at   a   right   angle. 

{!>)  The  phalanx  is  parallel  with  the  metacarpal  but  displaced  slightly 
back.  The  first  is  the  primary  position,  the  second  the  more  common  and 
the  result  of  attempts  at  reduction  :   the  backward  position  of  the  phalanx 

is   due  to  the   intervention   of   the  glenoid 

^  ligament   between   the  base  of  the  phalanx 

M         m  and  the  head  of  the  metacarpal. 

£       M  There   is  open   difficulty  in   reducing  this 

fy         ■  dislocation,    which    has    been    attributed    to 

M     2  the    head    of    the    metacarpal    being    caught 

A     m  between  the  heads  of  the  short  flexor  muscle 

or  in  the  tendon  of  the  long  flexor  :  it  is  doubt- 
ful if  these  are  of  any  importance.      The  real 
I      I  factor  which  interferes  with  reduc- 

tion (J.  Hutchinson,  jun.)  is  the 
f  glenoid  ligament:  this  is  carried 
back  with  the  phalanx,  to  which 
it  is  firmly  attached,  and  in  the 
primary  position  of  dislocation 
(a)  has  its  posterior  surface  still 
in  almost  the  normal  anterior 
relation  to  the  metacarpal  head, 
but  in  the  second  position  (b)  the  glenoid 
ligament  is  buckled  back  so  that  its  anterior 
surface  is  in  relation  to  the  posterior  surface  of 
the  metacarpal  head  and,  unless  it  is  split,  most 
effectually  prevents  reduction.  (F'g.  1 1 7.  a,  o.) 
Treatment.  When  in  the  first  position  (a) 
hyper-extension  followed  by  traction  and 
flexion  may  reduce  the  dislocation  or  may 
cause  it  to  assume  the  second  form  (6).  In  this 
second  position  it  is  necessary  to  introduce  a 
tenotome  into  the  thumb  behind,  in  the  mid-line,  and  proximal  to  the  project- 
ing  base  of  the  displaced  phalanx  :  it  is  thrust  forward  to  the  anterior  edge  of 
the  latter,  just  grazing  the  metacarpal  head,  and  thus  proximal  to  the  dis- 
placed glenoid  ligament ;  it  is  then  made  to  cut  on  to  the  base  of  the  phalanx 
and  infallibly  splits  the  glenoid  ligament  longitudinally.  When  the  glenoid 
ligament  is  surely  divided  reduction  by  the  manipulation  described  above  is 
easy.  Employed  in  a  good  many  instances,  we  have  never  known  this 
little  operation  fail.  Dislocations  of  the  other  metacarpo-phalangeal  joints 
are  similar  in  nature  and  treatment.     (Fig.  1 1 7,  b,  c.) 

(c)  Fractures  of  the  Phalanges.  These  occur  usually  in  the  middle 
of  the  bones  and  are  detected  by  the  deformity,  mobility,  and  crepitus.  The 
deformity  is  usually  in  the  direction  of  hyper-extension,  i.e.  the  bone  is 


of  the 


116.     Backward    dislocation 


thumb  at  the  metacarpo- 
phalangeal joint. 


FRACTURES  AND  DISLOCATIONS  OF  PHALANGES        301 

bowed  forward  in  its  middle.  Treatment  is  as  for  fractures  of  the  meta- 
carpal, i.e.  flexion  to  correct  the  hyper-extension. 

Fractures  also  occur  into  joints  near  the  base  of  a  phalanx  resembling 
Bennett's  fracture,  with  dislocation  back  of  the  interphalangeal  joint.  If 
careful  fixation  in  a  flexed  position  fails  to  produce  a  good  position  in  these 
cases,  it  will  be  necessary  to  remove  the  small  loose  fragment. 

Dislocation  of  the  phalanges  may  occur  forward  or  backward. 

( 1 )  Forward  dislocation  is  often  combined  with  rupture  of  the  extensor 
tendon,  and  generally  affects  the  last  phalanx  ;  the  characteristic  deformity 
is  known  as  "  mallet  finger." 

Treatment.  The  dislocation  is  readily  reducible,  but  if  the  extensor 
tendon  is  partially  torn  the  digit  must  be  kept  for  several  weeks  hyper- 


FiO.   117.     Dislocation  of  the  carpo-intercarpal  joint  of  the  thumb,     a,  Primary 

position  (reduction  by  manipulation  possible),     b,  Secondary  position  ;   the  glenoid 

ligament  displaced  back  and  joined ;  introduction  of  a  tenotome  shown,     c,  Anterior 

view  showing  the  glenoid  ligament  split  by  the  tenotome. 


extended,  while  the  tendon  unites  :  if  the  tendon  is  completely  divided,  as 
shown  by  absolute  loss  of  all  extension  at  this  joint,  it  will  be  necessary 
to  cut  down  and  suture  the  ruptured  tendon  to  the  periosteum  of  the 
phalanx. 

(2)  Dislocation  backward  of  the  last  phalanx  is  easily  reducible,  but  if 
the  flexor  tendons  are  torn  the  deformity  tends  to  recur  and  persist,  the 
condition  being  then  described  as  "  base-ball  "  finger,  and  the  treatment  is 
to  maintain  flexion  of  the  digit  for  some  weeks  or  to  suture  the  tendon, 
according  to  the  severity  of  the  lesion. 


A  TEXTBOOK  <>F  SURGERY 


B.  INJURIES   OF   THE   LOWER   LIMB 
i.    FRACTURES  OF   THE   PELVIS 

Si  rgical  Anatomy.  The  pelvis  may  be  regarded  as  a  double  arch, 
one  half  consisting  of  the  two  ilia  and  the  sacrum,  the  other  anterior  half 
ul  the  pnbes  and  ischia,  the  two  arches  meeting  at  the  acetabulum.  These 
arch  'led  tor  a  greal  part  of  their  extent  with  closely  applied  muscles 

and  fascia?,  the  result  being  that  when  a  fracture  occurs  in  one  arch  the 
other  very  often  escapes,  and  if  both  arches  are  broken  the  strong  soft 
tissues  attached  around  prevent  much  displacement  of  the  fragments.  A 
great  part  of  the  pelvis  is  subcutaneous;  thus  the  iliac  crests  the  iliac, 
pubic,  and  sacral  spines,  the  rami  of  the  pubis  and  ischium  as  well  as  the 
tuber  ischii  can  be  palpated  from  the  surface,  while  from  the  rectum  or 
vagina  a  great  part  of  the  true  pelvis  can  be  explored.  The  chief  importance 
of  fractures  of  the  pelvis  is  not  the  bony  lesion,  since  displacement  is  seldom 
great  or  disabling,  but  the  lesions  of  the  pelvic  viscera  fairly  often  associated 
with  fractures  of  the  pelvis  are  of  the  highest  moment,  as  will  be  realized 
on  reflecting  that  within  the  bony  walls  of  the  pelvis  are  included  such 
-tinctures  as  the  rectum,  bladder,  and  urethra. 

( 'auses  of  Fracture.  The  pelvic  arches  may  be  broken  by  direct  violence. 
such  as  crushes  under  wheels  or  gun-shot  injuries,  or  indirectly,  as  where 
the  ilia  are  forced  together  in  buffer  accidents  and  a  weak  part  of  the  arch 
L'ives  way  elsewhere  ;  the  usual  place  being  the  rami  of  the  ischium  and  pubis 
and  the  sacro-iliac  synchondrosis. 

Fractures  of  the  pelvis  may  be  conveniently  divided  into  (a)  those 
where  the  pelvic  arch  is  broken  up  and  where  there  is  danger  of  visceral 
injury  in  addition,  (b)  those  where  portions  of  the  pelvis  are  knocked  off 
without  interfering  with  the  arch  as  a  whole  and  in  which  injuries  to  the 
viscera  are  unlikely. 

(a)  Fractures  of  the  Pelvic  Arch.  The.  line  of  fracture  in  these 
cases  runs  through  the  horizontal  ramus  of  the  pubis  and  the  ascending 
ramus  of  the  ischium  in  front;  occasionally  only  one  of  these  is  broken 
(in  which  case  the  damage  may  be  considered  slight) ;  behind,  the  fracture 
intinued  through  the  sacro-iliac  synchondrosis  and  the  ilium  outside 
this,  on  the  same  side  as.  or  the  opposite  side  to,  the  anterior  fracture.  In 
more  severe  instances  the  pubis  may  be  broken  off  the  ilium  and  ischium 
on  both  sides  and  driven  backwards,  placing  the  urethra  and  bladder  in 
great  danger. 

Signs.  The  patient  as  a  rule  is  unable  to  walk,  but  if,  with  only  one 
ramus  of  pubis  or  ischium  broken,  this  is  possible,  he  complains  of  a  feeling 
as  though  the  pelvis  weir  falling  to  pieces.  Local  bruising  will  usually  be 
visible  over  the  pubis  on  one  side  ;  there  will  be  pain  on  moving  the  legs, 
and  if  the  iliac  (rests  are  grasped  by  the  surgeon  and  attempts  made  to 
move  them  there  will  be  pain,  abnormal  mobility,  and  perhaps  crepitus; 
per  rectum,  a  projecting  Eragmenl   may  be  detected.     Great  deformity  is 


FRACTURES  OF  THE  PELYI> 


303 


uncommon,  and  exact  diagnosis  will  as  a  ride  require  investigation  with 
X-rays. 

Injuries  to  Viscera.  In  all  cases  presenting  these  signs  great  care  must 
be  taken  to  exclude  injury  to  viscera,  since  early  diagnosis  is  the  secret  of 
success  in  treating  such  cases.  The  penis  should  be  examined  ;  bleeding 
from  the  urethra,  apart  from 
micturition,  suggests  rupture 
of  the  urethra.  A  catheter 
should  be  passed  and  the  con- 
dition of  the  bladder  inves- 
tigated (see  Injuries  of  the 
Bladder  and  Urethra).  Ex- 
travasation into  the  perineum, 
scrotum  or  lower  abdomen, 
which  suggest  rupture  of  the 
urethra,  should  be  noted.  The 
rectum  and  vagina  should 
always  be  examined  for  lacera- 
tion, caused  by  inwardly  pro- 
jecting fragments. 

Treatment.  In  uncompli- 
cated cases  it  is  sufficient  to 
confine  the  patient  to  bed  with 
a  firm  binder  round  the  pelvis 
for  three  to  six  weeks,  accord- 
ing to  the  amount  of  damage 
present.  A  fracture-board  will 
steady  the  pelvis  and  the  legs 
should  be  flexed  on  a  pillow 
under  the  sacrum,  a  water- 
pillow  will  prevent  the  occur- 
rence of  bed-sores.  After  this 
time  the  patient  is  allowed  to  sit 
up  and  walk  gradually.  Injuries 
to  the  pelvic  viscera  are  con- 
sidered under  the  Surgery  of  the 
Bladder,  Urethra,  and  Rectum. 

(6)  Fractures  of  Separate  Parts  of  the  Pelvis.  The  following  are 
described,  viz.  of  the  (1)  ilium,  (2)  ischium,  (3)  acetabulum.  (I)  sacrum. 
(■1)  coccyx. 

(1)  Portions  of  the  iliac  crest,  including  anterior  and  posterior  spines. 
may  be  broken  off  by  falls  or  severe  blows  ;  in  young  subjects  the  corre- 
sponding epiphyses  may  be  separated. 

Signs.  Bruising,  effusion,  abnormal  mobility,  and  crepitus  will  be 
Doted  :  separation  is  seldom  great  on  account  of  the  firm  attachment  of 
the  gluteal  and  oblique  muscles  to  both  fragments. 


Fig.   L18.     Fractures  of  the   pelvis.     I.  Tl 

the  pubic  ami  ischial  rami.      II.   Radiating  frac- 
ture through  the  acetabulum. 


304  A  TEXTBOOK  OF  SURGERY 

Treatment.  Confinement  to  bed  with  firm  binder  will  as  a  rale  suffice  : 
should  a  fragment  be  pulled  away  by  a  muscle,  e.g.  the  anterior  superior 
spine  by  the  sartorius,  it  should  be  fixed  by  a  wire  or  screw. 

j  The  ischium  is  usually  fractured  by  Tails  in  the  sitting  position  : 
separation  is  Beldom  great  owing  to  muscular  and  aponeurotic  attachments. 

§  Effusion  and  pain  in  this  region,  the  latter  Increased  by  flexing 

the  thigh  and  thus  stretching  the  attached  hamstring  muscles,  while  abnormal 
mobility  of  the  tuber,  on  the  rest  of  the  pelvis,  and  sometimes  crepitus, 
will  be  made  out. 

Treatment.  In  the  usual  eases  where  displacement  is  aegligible,  resl 
in  bed  for  three  weeks  and  gradual  return  to  walking.  Where  the  tuber  ischii 
Is  pulled  down  by  the  hamstrings  open  operation  should  be  done  by  posterior 
incision  and  the  tuber  fixed  in  position  by  a  screw. 

■  i  Two  varieties  of  fracture  of  the   acetabulum  will  be  noted  ;    (a)  of 
the  posterior  and  upper  part  of  the  lip  ;   (b)  of  the  cavity  itself. 

(a)  This  fracture  is  associated  with  direct  dislocation  backward  of  the 
femur,  which  knocks  off  the  lip  of  the  acetabulum  in  this  position  when 
driven  up  and  backward. 

Signs  are  those  of  dorsal  dislocation  of  the  hip,  but  the  deformity  can 
be  readily  reduced  by  traction  on  the  limb,  and  as  easily  recurs  again 
when  the  extending  force  is  remitted,  i.e.  there  is  telescopic  movement 
present. 

Treatment  consists  in  placing  the  limb  on  a  long  splint  (Liston)  with 
weight-extension  of  10  to  15  pounds  ;  radiographs  will  show  if  position  is 
satisfactory,  when  union  will  occur  in  six  to  eight  weeks,  after  which  a 
Thomas's  knee-splint  should  be  worn  for  three  months  to  prevent  the 
weight  of  the  limb  pushing  the  newly  united  fragment  out  of  place.  Where 
the  position  is  unsatisfactory  with  use  of  extension,  operative  measures  will 
be  indicated  in  young  subjects  :  the  trochanter  will  be  temporarily  detached 
with  the  gluteal  muscles  to  expose  the  joint  freely,  and  the  fragment  fixed 
with  screw's  or  pegs. 

(b)  The  cavity  of  the  acetabulum  may  be  simply  fissured  or  broken  into 
its  component  parts,  in  which  latter  case  the  head  of  the  femur  may  be 
driven  right  through  the  acetabulum  into  the  cavity  of  the  pelvis  (internal 
dislocation  of  the  femur). 

Signs.  A  fissured  fracture  can  hardly  be  distinguished  from  severe 
contusion  of  the  part  except  by  good  radiographs.  The  more  severe  variety 
will  show  flattening  of  the  hip  on  the  injured  side,  the  t  roehanter  being  nearer 
the  mid-line  (bi-trochanteric  measurement,  p.  307)  and  displaced  upward  : 
i.e.  the  condition  will  resemble  a  case  of  fracture  of  the  neck  of  the  femur, 
but  there  will  be  no  eversion  of  the  foot — on  the  contrary  rather  inversion 
and  movement  will  be  diminished  and  not  abnormally  free:  further,  the 
head  of  the  femur  will  be  felt  inside  the  pelvis  on  rectal  examination. 

Treatment.  Fissured  fractures  need  rest  in  bed  for  a  lew  days,  followed 
by  massage,  and  weight  should  not  be  placed  on  the  limb  for  some  weeks. 

The  severe  variety  requires  to  be  reduced  by  traction  in  the  axis  of 


FRACTURES  OF  THE  COCCYX  305 

the  limb  (under  anaesthesia)  combined  with  traction  outward,  and  circum- 
duction of  the  femur  to  deliver  the  head  from  the  pelvis. 

When  reduced  the  limb  is  placed  on  the  long  splint  with  weight- extension 
for  a  month  to  prevent  recurrence,  after  which  passive  movement  may  be 
commenced  and  a  Thomas's  knee-splint  provided — with  which  appliance 
the  patient  may  walk,  but  no  weight  should  be  borne  on  the  limb  itself 
for  at  least  three  months.     In  any  case  ankylosis  is  a  likely  result. 

(±)  The  sacrum  is  rarely  fractured  except  in  severe  smashes  of  the 
pelvis  :  fractures  of  this  bone  are  never  common,  but  it  may  be  fractured 
alone  by  falls  or  severe  blows  in  this  region. 

Signs.  The  fracture  is  more  or  less  transverse  and  the  lower  fragment 
is  displaced  forwards,  where  it  may  injure  the  rectum. 

Signs.  Severe  bruising  over  the  lower  part  of  the  sacrum  with  crepitus 
and  abnormal  mobility  of  the  lower  part,  and  per  rectum  a  projection  of  the 
bone  will  render  the  diagnosis  clear.  The  rectum  should  be  always  care- 
fully examined  in  such  cases  to  exclude  injury  to  the  latter. 

Treatment.  The  fragment  should  be  manipulated  back  into  position 
with  the  finger  in  the  rectum,  and  the  patient  kept  on  the  side  for  a  month 
to  prevent  the  fragment  being  pushed  forward  again  and  thus  injuring  the 
rectum  (see  Surgery  of  the  Rectum  for  lacerations  of  this  organ). 

(5)  Fractures  of  the  Coccyx.  These  are  due  to  falls  or  blows  on  the  bone 
which  is  driven  forward. 

Signs.  The  coccyx  will  be  movable  on  the  sacrum,  and  in  addition  to 
the  usual  signs  of  injury  there  will  be  great  pain  on  defgeeation  and  coughing, 
both  due  to  alteration  of  the  tension  of  the  pelvic  floor  (levator  ani  muscle) 
which  is  attached  to  the  coccyx.  If  the  bone  is  much  bent  forward  it  may 
prove  a  mechanical  obstruction  to  defsecation. 

Treatment.  The  coccyx  is  replaced  by  a  finger  in  the  rectum  and  the 
patient  kept  on  the  side  as  in  fractures  of  the  sacrum.  Should  the  pain 
and  disability  persist  in  spite  of  such  treatment  the  little  bone  should  be 
removed  by  a  posterior  incision. 

Coccygodynia.  Injuries  to  the  coccyx,  with  or  without  fracture,  are  often 
followed  by  troublesome  pain  in  the  part,  which  is  exaggerated  on  sitting 
or  defaecation.  If  rest  and  counter-irritants  fail  to  cure,  the  offending  bone 
is  best  removed. 

2.  INJURIES  ABOUT   THE  HIP-JOINT 
The  following  are  described  :    Sprains  and  dislocations  of  the  joint  : 
fractures  of  the  upper  end  of  the  femur. 

Anatomy.  The  hip-joint,  though  allowing  of  free  movement,  is  of 
great  strength  both  from  the  depth  of  the  socket  (acetabulum),  which 
affords  a  good  resting-place  for  the  head  of  the  femur,  and  on  account  of 
the  strength  of  the  ligaments,  which,  like  those  of  the  shoulder- joint,  are  of 
greatest  strength  above,  in  front,  and  behind  (the  ilio-femoral,  or  Y-ligament, 
and  the  ischio-femoral  band),  the  lower,  or  pubo-femoral  part,  being  weaker  ; 
this  and  the  fact  that  the  cotyloid  notch  which  renders  the  rim  of  the  aceta- 


306 


\  TEXTBOOK  OF  SURGERY 


Imluni  less  prominent  in  the  lower  and    front  part  of   its   extent,  explains 
th«'  frequency  of  dislocations  through  the  Lower  part  of  the  capsule. 

b  regards  bony  Land-marks,  besides  the  anterior  superior  spines  and 
the  tuber  ischii  already  mentioned,  the  great  trochanter  can  be  readily 
palpated,  and  its  tip  is  a  fairly  definite  point  in  patients  moderately  covered, 
though  in  obese  subjects  the  point  is  hard  to  make  out  with  accuracy.  The 
head  of  the  femur  can  be  felt  under  the  femoral  vessels,  but  not  readily; 
its  absence,  however,  leaves  a  feeling  of  want  of  resistance  at  this  point. 

i.e.  below  the  middle  of  Poupart's 
ligament.  The  following  points 
are  also  worthy  of  note. 

Nelaton's  Line.  This  line  joins 
the  anterior  superior  spine  and  the 
lower  end  of  the  tuber  ischii  and 
passes  exactly  over  the  tip  of  the 
great  trochanter  ;  consequently,  if 
the  latter  is  above  or  below  this  line 
there  must  be  some  change  in  the 
neck  or  head  of  the  femur.  (Fig.  1 1 9. ) 
Bryant's  Lines  and  Measure- 
ments. The  patient  being  recum- 
bent, two  vertical  lines  are  drawn 
through  the  anterior  superior  spine 
and  the  tip  of  the  great  trochanter ; 
the  distance  between  these  parallel 
lines  is  normally  about  two  and  a 
half  inches  :  if  the  trochanter  is 
displaced  upwards  for  any  reason, 
whether  dislocation  of  the  head  of 
the  femur  or  bending  or  fracture 
of  the  neck,  the  distance  will  be  altered  on  the  affected  side ;  in  marked 
instances  the  anterior  superior  spine  and  the  tip  of  the  trochanter  may  be 
on  the  same  level.   (Fig.  119.) 

The  Bi-trochanteric  Measurement  (Morris).  This  consists  in  measuring 
the  distance  of  the  great  trochanter  from  the  mid-line  (symphysis  pubis) 
on  either  side  ;  in  cases  where  the  neck  of  the  femur  is  broken  or  the  head 
driven  into  the  acetabulum,  &c,  the  measurement  will  be  diminished  on 
the  affected  side.    (Fig   120.) 

The  excursion  of  the  trochanter  is  another  method  of  ascertaining  the 
same  fact.  When  the  leg  is  grasped  and  the  femur  thus  rotated,  the 
trochanter  rotates  about  the  acetabulum  as  a  centre  in  the  arc  of  a  relatively 
large  circle,  but  if  the  neck  of  the  bone  is  broken  the  rotation  will  be  about 
the  point  of  fracture,  i.e.  the  arc  of  rotation  will  be  of  a  smaller  circle  and 
the  excursion  of  the  trochanter  diminished. 

The  Tension  of  the  Fascia  Lata.  The  fascia  lata  is  normally  stretched 
over  the  trochanter  and  has  a  certain  tension.     When  the  neck  of  the  bone 


In  .    119.     The  relation  of  bony  parts  about 

the  hip.     a,  Bryant's  measurement,     b,  Nela- 

ton's  line. 


DISLOCATION  OF  THE  HIP 


307 


is  broken  the  trochanter  is  displaced  up  and  falls  inward,  and  so  the  tension 
on  the  fascia  is  diminished  and  the  latter  feels  relatively  slack  on  the  affected 
side. 

(a)  SPRAINS  AND  DISLOCATIONS  OF  THE  HIP-JOINT 

(1)  Sprains  of  the  hip-joint  are  chiefly  important  as  leading  to  confusion 
in  diagnosis.  Important  injuries,  as  separation  of  the  upper  epiphysis  of 
the  head  of  the  femur,  may  be  mistaken  for  a  simple  sprain  unless  care 


a  - 


Fig.  120. 


Bi-trochanteric  measurement,     be  is  less  than  ab  because  of  the  shortened 
neck  of  the  femur. 


be  exercised,  and  the  sequela?  of  such  injuries  are  serious,  as  will  be  shown 
later. 

(2)  Dislocations  of  the  Hip-joint.  Anatomy.  The  hip-joint  owes  its 
strength  partly  to  the  depth  of  the  acetabulum  and  the  accuracy  with  which 
the  head  of  the  femur  fits  this  socket,  partly  to  the  strong  ligaments  which 
surround  the  joint.  Of  these  the  most  important  are  :  (a)  The  ilio-femoral 
or  Y -ligament  (Bigelow),  which  extends  from  the  anterior  inferior  spine  of 
the  ilium  to  the  upper  and  lower  extremities  of  the  anterior  inter-trochan- 
teric  line.  This  is  of  great  strength,  is  hardly  ever  ruptured,  and  is  of 
great-  value  in  reducing  ordinary  dislocations,  since  it  acts  as  a  strong  stay 
between  the  upper  end  of  the  femur  and  the  pelvis,  producing  inversion  or 
eversion  of  the  former,  and  about  which  the  head  of  the  bone  can  be 
manoeuvred  back  to  its  position  in  the  acetabulum  ;  it  also  strengthens  the 
front  and  upper  part  of  the  joint. 


A  TKXTHOOK  OF  STROERY 

(6)  The  Becond  important  ligament  is  the  ischio-femoral,  which  passes 
from  the  ischium  to  the  middle  part  of  tin'  posterior  surface  of  the  neck 

of  the  femur  and  Btrengthens  the  joint  above  and  at  the  back.  It  will  be 
noted  that,  as  in  the  case  of  the  shoulder,  tin-  lower  part  of  the  capsule  is 
the  weakest  part,  and  it  is  through  this  part  that  dislocations  usually  occur, 
dislocation  directly  upwards  being  a  rare  condition  and  nearly  always 
associated  with  fracture  of  the  lip  of  the  acetabulum  in  this  situation  (see 
Ki;icture  of  tin1  Acetabulum   p.  304). 

Causes.  Dislocation  of  the  hip  is  always  produced  by  indirect  violence, 
which  is  usually  of  such  a  nature  as  to  produce  abduction  of  the  femur  ;  in 
this  way  the  head  is  forced  through  the  weak  lower  part  of  the  capsule, 
after  which  it  passes  forward  or  backward  according  to  the  direction  of  the 
dislocating  force,  giving  rise  to  several  varieties  of  dislocation. 

Varieties  of  Dislocation.  In  nearly  all  cases  the  Y-ligament  remains  intact 
and  the  dislocations  are  described  as  regular.  In  the  uncommon  types, 
where  the  ligament  is  torn,  the  dislocations  are  known  as  irregular. 

Regular  Dislocations.  Of  these  four  varieties  are  described  :  dorsal, 
sciatic,  thyroid,  and  pubic. 

It  will  be  seen  that  in  two  the  head  passes  forward  and  in  the  other  two 
backward  ;  the  latter  are  the  more  common  variety,  and  the  dorsal  type 
form  more  than  half  the  dislocations  of  this  joint. 

(1)  The  Dorsal  Dislocation.  The  head  lies  on  the  dorsum  ilii  above  and 
behind  the  acetabulum  and  above  the  tendon  of  the  obturator  interims, 
having  as  a  rule  passed  out  below7  the  latter  and  afterwards  slipped  above 
it ;  less  often,  in  dislocations  in  the  adducted  position  the  head  may  pass 
out  of  the  capsule  above  this  tendon.  The  external  rotator  muscles  and 
the  ligamentum  teres  are  torn. 

Signs.  The  head  may  be  felt  in  spare  subjects  behind  the  great  tro- 
chanter under  the  gluteal  muscles,  while  there  is  an  unnatural  hollow  at 
the  base  of  Scarpa's  triangle,  leaving  the  femoral  vessels  unsupported,  as 
noticed  on  palpation.  The  tip  of  the  great  trochanter  will  be  well  above 
Xelaton's  line,  the  thigh  flexed,  adducted  and  inverted  (rotated  inwrards), 
so  that  the  ball  of  the  great  toe  on  the  affected  side  will  rest  on  the  dorsum 
of  the  other  foot  wrhen  the  legs  are  extended.  The  joint  will  be  unnaturally 
fixed,  and  measurement  from  the  anterior  superior  spine  to  the  internal 
malleolus  will  show  shortening  of  twro  to  three  inches  on  the  side  of  dislocation. 

(2)  The  Sciatic  Dislocation  ("  dorsal  below  the  tendon/'  of  Bigelow).  In 
this  variety  the  head,  having  passed  through  the  lower  part  of  the  capsule, 
remains  below7  the  tendon  of  the  obturator  internus,  which  prevents  it 
from  passing  on  to  the  dorsum  ilii  and  keeps  it  in  the  sciatic  notch.  The 
external  rotators  and  round  ligament  are  torn  as  in  the  former  variety. 

Signs.  The  head  may  perhaps  be  made  out  on  the  dorsum,  but  in  a 
lowei  position  than  in  the  dorsal  variety  ;  the  hollowing  of  Scarpa's  triangle 
is  also  found.  Adduction  and  inversion  of  the  thigh  are  present  but  flexion 
is  less  marked,  the  ball  of  the  toe  resting  on  the  dorsum  of  the  great  toe-joint 
of  the  sound  side,  i.e.  there  is  less  shortening. 


DISLOCATIONS  OF  THE  HIP 


309 


(3)  The  Obturator  or  Thyroid  Dislocation  (perineal  dislocation).  Of  the 
more  rarely  occurring  forward  dislocations  that  into  the  thyroid  foramen 
is  the  more  common.  In  this  form  the  femoral  head,  after  passing  through 
the  lower  part  of  the  capsule,  travels  slightly  forward  so  as  to  rest  on  the 
obturator  externus,  where  it  can  be  felt  in  the  perineum.  The  ligamentum 
teres  is  ruptured  and  the  adductors  and  pectineus  muscles  torn  or  tense. 
The  intact  ilio-femoral  ligament  produces  external  rotation  (eversion)  of 
the  thigh  with  flexion  ;  the  great  trochanter  is  less  prominent  than  usual 
and  the  leg  appears  and  may  actually  be  longer  than  on  the  sound  side. 

Signs.  The  thigh  is  flexed,  abducted,  and  rotated  outwards.  The 
flexion  varies,  being  greater  the  more  the  head  is  displaced  towards  the 


Fig.  121.     Dorsal  dislocation  of 
the  femur. 


Fig.  122.     Thyroid  dislocation  of 
the  femur. 


tuber  ischii.  The  head  can  be  felt  in  the  perineum,  while  the  prominence 
of  the  trochanter  is  diminished. 

(4)  The  pubic  is  the  least  common  of  all  the  regular  dislocations.  In  this 
variety  the  head,  after  leaving  the  capsule,  travels  up  and  inwards,  to 
rest  on  the  horizontal  ramus  of  the  pubis  internal  to  the  anterior  inferior 
spine.  The  ilio-psoas  muscle,  with  the  femoral  vessels  and  the  anterior 
crural  nerve,  are  pushed  inwards.  The  external  rotators  and  the  liga- 
mentum teres  are  torn. 

Signs.  The  head  can  be  felt  in  its  new  position,  as  it  is  superficial.  The 
prominence  of  the  trochanter  is  missing  owing  to  the  inward  displacement 
of  the  bone,  but  the  most  notable  result  is  the  great  outward  rotation  of 
the  thigh  produced  by  the  intact  Y-ligament ;  the  thigh  is  also  abducted 
and  flexed  and  the  limb  shortened. 

Irregular  Dislocations.  In  these  the  everted  dorsal  is  the  only  one 
requiring  mention. 

Here  the  head  of  the  bone  is  close  to  the  anterior  inferior  spine,  but  to 
its  outer  side  on  the  dorsum  ilii ;  the  thigh  is  everted,  being  allowed  to 
assume  this  position  by  rupture  of  the  outer  part  of  the  Y-ligament.     The 


310 


A  TEXTBOOK  OF  SVROERY 


dorsal  position  with  eversion  characterizes  this  type.  Reduction  is  as  for 
other  dorsal  dislocations. 

Treatment.  Reduction  of  these  dislocations  may  be  effected  by 
(1)  manipulation  and  traction,  (2)  by  operative  measures. 

The  aim  of  manipulation  is  to  cause  the  head  of  the  bone  to  retrace  its 
course  till  it  lies  below  the  rent  in  the  capsule,  when  it  can  be  made  to  slip 
back  into  the  socket  by  an  appropriate  manoeuvre. 

The  anaesthetised  patient  is  laid  on  his  back  on  a  mattress  on  the  floor 
and  the  pelvis  lixed  by  one  or  more  assistants  pressing  on  the  iliac  crests 
and  symphysis  pubis. 

The  surgeon  next  ilexes  the  leg  on  the  thigh  and  the  thigh  acutely  on 
the   abdomen    to    relax   the   strong    muscles   (rectus   femoris,    hamstrings 


Fig.  123.     Course  of  the  head  of 
the  femur  during  reduction. 


FlG.  124.  Pveduction  of  a  dorsal  dis- 
location of  the  hip,  showing  how  it 
may  pass  into  the  thyroid  variety 
unless  traction  be  exercised  along  the 
femur  or  the  latter  comes  to  a  right 
angle  with  the  trunk. 


and  ilio-psoas)  about  the  joint.  The  flexed  knee  is  then  circumducted  in 
an  opposite  direction  to  that  in  which  it  is  displaced.  If  adducted  and 
inverted,  as  obtains  in  backward  dislocations,  the  knee  is  circumducted 
outwards  ;  this  has  the  effect  of  making  the  head,  tethered  by  the  Y-liga- 
ment.  to  move  inwards  and  downwards  so  that  it  comes  to  lie  below  the 
acetabulum.  It  may  readily  pass  from  this  position  through  the  rent  in  the 
capsule  with  the  usual  sucking  click,  and  be  reduced.  In  some  instances, 
however,  the  head  will  pursue  its  course  around  the  prominent  lip  of  the 
acetabulum  and  land  over  the  thyroid  foramen  or  pubis,  the  dislocation 
being  converted  into  one  of  the  forward  variety.  To  prevent  this  happening, 
as  the  knee  passes  the  mid-position  of  the  limb  in  circumduction,  traction 
should  be  made  in  the  direction  of  the  axis  of  the  femur,  i.e.  with  the  patient 
lying  on  his  back,  vertically;  this  little  manoeuvre  will  cause  the  head  to 
jump  the  projecting  lip  of  the  acetabulum  and  slip  through  the  rent  in  the 
capsule,  passing  into  its  socket. 

77'  atment  of  forward  dislocations  only  differs  from  the  backward  variety 


REDUCTION  OF  A  DISLOCATED  HIP  311 

in  the  direction  in  which  the  thigh  is  circumducted.  In  these  dislocations 
the  thigh,  after  flexion  in  the  everted  and  abducted  position,  is  then  rolled 
or  circumducted  inward,  which  causes  the  head  to  pass  outward  under 
the  acetabulum,  where  there  is  the  same  danger  of  its  passing  along  into 
the  dorsal  position,  unless  at  the  critical  mid-position  traction  be  made  in 
the  direction  of  the  femoral  axis  as  the  head  passes  the  rent  in  the  capsule. 

To  recapitulate,  (1)  flex  the  thigh  and  knee,  (2)  circumduct  the  thigh 
in  the  opposite  direction  to  that  to  which  it  points,  (3)  pull  the  thigh  in 
the  axis  of  the  femur  as  it  passes  the  mid-position,  (4)  extend  the  thigh. 

Reduction  by  manipulation  is  usually  successful  up  to  within  two  to 
three  months  of  the  dislocation,  after  which  time  failure  is  probable  and 
recourse  must  be  made  to  stronger  measures.  It  is  questionable  if  very 
powerful  traction  by  means  of  a  tackle  of  pulleys  attached  to  the  thigh, 
with  counter-extension  by  means  of  a  perineal  band,  is  worth  the  risk  thus 
involved  of  injury  to  nerves,  vessels  and  bones.  Better  is  it  to  apply 
continuous  weight- extension  for  a  week  and  then  attempt  reduction  by 
manipulation,  the  shortened  muscles  being  by  that  time  stretched  to  some- 
thing like  their  normal  length  ;  and,  failing  this,  to  pass  to  (2)  open 
operation. 

(2)  Open  Operation.  The  best  manner  of  exposing  the  joint  is  by  turning 
up  a  flap  over  the  great  trochanter  and  temporarily  resecting  this  from 
the  rest  of  the  bone  and  displacing  with  the  muscles  attached  ;  this  gives 
good  access  to  the  head  and  acetabulum,  which  are  cleared  of  adhesions 
and  redundant  fibrous  tissue  and  the  head  manoeuvred  into  position  in 
the  acetabulum.  The  trochanter  is  fastened  again  to  the  femoral  shaft 
and  the  limb  placed  on  a  splint  with  weight-extension  for  a  month  to  prevent 
re-dislocation,  when  massage,  active  and  passive  movements  may  be 
commenced. 

The  after-treatment  of  ordinary  cases  where  reduction  is  effected  by 
manipulation  alone  is  rest  in  bed  for  three  to  seven  days,  according  to  the 
amount  of  bruising  and  age  of  the  patient,  with  massage  and  movement 
after  three  days.  The  patient  can  usually  walk  in  a  few  days.  The  only 
movement  to  be  avoided  for  several  weeks  is  abduction  ;  otherwise,  apart 
from  complicated  cases  where  the  acetabular  lip  is  broken  off,  there  is  but 
little  tendency  for  the  dislocation  to  recur. 

(b)   FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR 

The  following  varieties  are  described  : 

(1)  Of  the  neck  near  the  head  (intracapsular). 

(2)  Of  the  neck  near  its  base  (partially  extracapsular). 

(3)  Through  the  base  of  the  neck  and  trochanters  (per-trochanteric  and 
wholly  extracapsular). 

(4)  Fracture  of  the  great  trochanter. 

(5)  Separation  of  the  epiphysis  of  the  head. 

(1)  Fracture  of  the  neck  near  the  head,  which  is  a  truly  intracapsular 
fracture,  occurs  in  old  persons,  usually  women,  and  from  slight  violence, 


312  \  TKXTBOOK  OF  SiHdKKV 

such  as  tripping  over  stairs,  carpels,  &c.,  and  is  due  rather  to  tin1  atrophic 
condition  of  the  bone  in  tins  situation  in  old  people  than  to  the  violence  of 
the  iujurv. 

Displacement.  The  fragments  may  he  held  together  by  the  folds  of 
reflected  synovial  membrane  covering  the  periosteum  (retinacula),  but 
often  this  frail  bond  is  completely  torn  through  :  rarely  the  neck  is  impacted 
in  the  cancellous  tissue  of  the  head.  Unless  impacted,  separation  of  the 
fragments  takes  place,  the  lower  fragmenl  being  drawn  up  by  the  muscles 
arising  from  the  pelvis  and  attached  to  the  femur  and  tibia,  and  is  rotated 
outwards  partly  by  the  weight  of  the  limb,  partly  by  the  fact  that  the 
neck  of  the  bone  gives  way  more  at  the  back  than  in  front.  When  impac- 
tion occurs  the  displacement  is  slight,  but  eversion  of  the  foot  is  usually 
noted. 

S  n's.  There  are,  as  a  rule,  but  few  signs  of  trauma  about  the  joint 
owing  to  the  slight  amount  of  violence.  Pain  and  loss  of  voluntary  move- 
ment are  usually  marked,  but  in  some  instances  the  patient  can  walk  on 
the  limb.  The  limb  is  everted  as  a  rule,  rarely  inverted,  and  shortened  to  the 
extent  of  one-half  to  one  inch.  The  trochanter  is  displaced  up  and  inwards, 
as  indicated  by  Bryant's  lines,  the  bitrochanteric  measurement,  the  dimi- 
nished excursion  of  the  trochanter  on  rotating  the  thigh,  and  the  loss  of 
tension  of  the  ilio-tibial  band.  Crepitus  is  usually  present  unless  impaction 
has  occurred. 

The  age  of  the  patient,  the  slight  diminution  of  the  bitrochanteric 
measurement,  and  only  slight  reduction  of  the  excursion  of  the  trochanter 
will  distinguish  from  fractures  near  the  base  of  the  neck. 

The  absence  of  any  displacement  of  the  head  on  the  pubis  excludes 
pubic  dislocation  of  the  hip,  the  only  dislocation  with  which  it  is  likely 
to  be  confused.  Mistaking  this  injury  for  osteo-arthritis,  with  or  without 
a  contusion  of  the  hip,  is  the  most  usual  error  which  arises,  as  both  conditions 
are  common  in  old  persons,  and  shortening  of  the  neck,  eversion  of  the  foot, 
and  crepitus  of  a  kind  will  also  be  present  in  osteo-arthritis.  A  history  of 
previous  limping  and  pain  in  the  joint,  projection  rather  than  flattening 
of  the  1 1  ochanter.  and  no  slackening  of  the  ilio-tibial  band  will  point  to  osteo- 
arthritis rather  than  fracture,  but  in  some  cases  X-rays  will  be  needed  to 
make  the  diagnosis.  Moreover,  it  must  be  realized  that  contusion  of  the 
hip  leads  later  in  many  instances  to  osteo-arthritis  and  deformity,  with 
suspicion  that  the  surgeon  has  incorrectly  diagnosed  the  condition  in  the 
first  place.  Therefore  patients  of  advancing  years  should  be  warned  of 
.-u'li  sequelae  to  apparently  simple  contusions  of  the  joint. 

Tr<at)tiivt.  When  occurring  in  old  persons,  as  is  usually  the  case,  rest 
in  bed  and  extension  will  almost  certainly  be  complicated  by  pneumonia, 
which  is  likely  to  carry  off  the  patient,  and  will  not  improve  the  limb  to 
any  great  extent  :  after  resting  a  few  days  in  bed  the  patient  should  be 
placed  in  a  Thomas's  hip-splint,  with  traction  on  the  leg  by  plaster  stirrup 
and  elastic  extension,  or  the  limb  should  be  put  up  in  complete  abduction 
in  a  long  plaster  teaching  from  the  ankle  to  the  costal  margin.     This  will 


WEIGHT-EXTENSION"  for  fractures 


313 


give  the  best  anatomical  position,  according  to  Whitman,  and  the  best 
chance  of  bony  union.  In  patients  with  good  physique  an  attempt  may 
be  made  to  secure  bony  union  by  placing  the  limb  on  a  long  (Liston's)  splint 
(Fig.  125) — or,  better  still,  in  the  abduction  box-splint — with  weight-exten- 
sion, and  leaving  in  this  position  for  six  weeks  if  the  fragments  are  in  good 
position,  after  which  the  patient  walks  with  a  Thomas's  calliper  knee-splint,  so 
that  no  weight  is  taken  on  the  neck  of  the  bone 
for  four  months  or  more.  Radiographs  should  be 
taken  after  extension  has  been  acting  for  three 
days,  and  if  good  position  is  not  obtained  by  this 
method  the  abduction  method  of  Whitman  should 
be  employed,  placing  the  fully  abducted  and 
extended  leg  in  a  long  spica. 

Weight-extension.  This  is  a  most  useful  adjunct 
in  treating  many  conditions  of  the  hip  and  femur 
and  may  well  be  described  here.  The  principle 
consists  in  fastening  a  weight  to  the  foot  by  a 
string  which  runs  over  a  pulley  at  the  foot  of 
the  bed,  so  that  a  constant  tension  is  acting  on 
the  limb  in  its  long  axis  :  at  the  same  time  the 
patient  is  prevented  from  sliding  down  the  bed 
in  obedience  to  this  tension,  either  by  tilting  the 
foot  of  the  bed  so  that  the  patient  tends  to  slide 
in  the  opposite  direction,  away  from  the  tension 
of  the  weight,  or  the  patient  is  fastened  to  the 
bed  by  a  band  passing  under  the  perineum. 
The  weight  is  attached  to  the  limb  as  follows  : 
A  ""  stirrup  "  is  made  consisting  of  a  piece  of 
wood  4  by  2|  in.  enclosed  in  a  long  piece  of 
strapping  which  extends  from  the  wooden  cross- 
piece  up  to  the  top  of  the  thigh.  The  strapping 
is  of  double  thickness  where  it  embraces  the 
wooden  cross-piece  and  for  a  foot  above  this  ;  the 
rest  is  of  single  thickness,  the  inner  layer  being 
absent  so  that  the  sticky  side  is  against  the  leg  and 
thigh.  The  stirrup  is  placed  so  that  the  cross-piece 
is  two  inches  below  the  sole  of  the  foot,  while  the  long  pieces  of  strapping 
extend  up  the  limb  on  either  side  and  are  fastened  to  this  by  short  pieces 
of  strapping  applied  in  a  circular  manner.  A  strip  of  Gamgee  tissue  should 
be  placed  between  the  strapping  and  the  malleoli  of  the  tibia  to  prevent 
the  formation  of  pressure-sores  over  these  superficial  prominences.  It 
should  be  noted  that  the  two  places  where  the  strapping  gets  a  grip  are 
above  the  malleoli  and  condyles,  and  attention  should  be  directed  to  placing 
strapping  tight  enough  above  the  latter  to  obtain  a  good  grip,  else 
the  main  tension  will  come  on  the  malleoli  and  will  overstretch  the 
ligaments  of  the  knee,  causing  long-lasting   stiffness  (one  of  the  greatest 


Fig.     125.      Box -splint     or 

double    long     Liston    splint 

with  weight-extension  of  the 

affected  limb. 


314  A  TEXTBOOK  OF  SURGERY 

troubles  aftei  fractures  of  the  femur,  treated  by  extension).  When  the 
short  strips  of  strapping  have  been  applied  to  six  inches  above  the  condyles 
the  finis  of  the  long  pieces  are  turned  down  over  those  and  fixed  with  one 
or  more  circular  strips.  In  the  centre  of  the  wooden  cross-piece  is  bored 
a  hole  to  take  a  String  to  which  is  attached  the  weight,  the  string  passing 
over  a  pulley  fastened  to  the  foot  of  the  bed  in  a  position  to  exert  suitable 
traction.  The  weight  varies  from  three  to  fifteen  pounds  ;  if  more  than  this 
there  is  risk  of  the  strapping  being  pulled  off.  The  strapping  should  be 
allowed  twenty-four  hours  to  set  before  the  weight  is  applied.  Weight- 
extension  applied  in  this  manner  maybe  used  with  a  variety  of  splints,  or 
instead  of  a  weight,  traction  may  be  made  with  elastic  bands  fastened  to 
t  he  wooden  cross-piece  and  attached  to  some  fixed  object  at  their  other  end, 
as,  e.g.  the  bottom  bar  of  a  Thomas's  knee-splint  (Jones). 

Nail-extension  (Steinmann)  deserves  a  brief  reference  here.  Instead 
of  fastening  the  weight  to  the  limb  by  strapping,  nails  are  driven  into  the 
bones  and  the  weight  attached  to  these  ;  this  plan  has  the  advantage  that 
greater  weight  can  be  used  without  danger  of  slipping,  but  has  the  dis- 
advantage usual  with  all  cases  where  metal  structures  are  left  protruding 
through  the  skin.  viz.  that,  in  spite  of  all  aseptic  precautions,  infection 
of  the  bone  may  take  place. 

Liston's  long  splint  is  a  straight  lath  extending  from  the  axilla  to  six 
inches  below  the  foot  and  about  four  inches  in  width,  well  padded  on  the 
side' next  the  body  and  limb  ;  a  short  cross-bar  at  the  lower  end  is  useful 
to  prevent  rotation.  This  splint  is  applied  as  follows  :  The  extension  stirrup 
is  fastened  to  the  limb  as  described  above,  and  then  the  splint  is  applied 
to  the  body  with  strips  of  Gamgee-tissue  intervening  as  well  as  the  padding, 
and  the  splint  bandaged  to  the  patient  thus  :  two  turns  of  a  domette 
bandage  are  placed  round  the  ankle,  applying  the  inner  side  of  the  bandage 
next  the  ankle;  after  which  the  bandage  is  carried  round  the  ankle  and 
splint  in  the  usual  manner,  and  after  two  turns  have  been  taken  in  this 
manner  one  is  made  round  the  foot  to  prevent  dropping  of  the  latter  (which 
must  be  kept  at  a  right  angle  with  the  leg),  and  then  the  bandage  is  carried 
up  to  the  groin.  The  splint  is  fastened  above  by  a  wide  flannel  roller 
bandage,  passed  round  the  chest  a  few  times,  and  fixed  to  the  splint  on  small 
hooks  or  belaying-pins.  In  cases  of  fracture  of  the  neck  of  the  femur  six 
weeks  on  the  splint  will  be  long  enough,  after  which  the  patient  should 
begin  to  walk  in  a  plaster-spica,  keeping  the  foot  off  the  ground  for  four 
months  :  a  better  plan  when  it  can  be  afforded  is  to  use  a  Thomas's  calliper 
knee-splint,  which  has  the  advantage  of  preventing  any  weight  being  placed 
on  the  limb,  while  the  splint  can  be  readily  removed  and  allows  of  massage 
and  later,  exercise  of  the  limb  without  undue  straining. 

Prognosis  of  these  eases  on  the  whole  is  bad,  owing  chiefly  to  the  age 
of  the  patient,  whose  hours  unite  badly,  while  the  prospect  of  his  being 
carried  off  by  pneumonia  is  no  small  one. 

I  nion  is  usually  fibrous  except  in  impacted  cases,  and  therefore  dis- 
impaction   is   contra-indicated.     The  results  when   occurring  in  younger 


FRACTURES  OF  THE  FEMORAL  NECK  315 

persons  should  be  better  if  reasonable  care  is  taken  to  reduce  the  fragments 
by  abduction  or  extension.  Operative  measures  may  be  attempted,  which 
consist  in  driving  a  nail  or  screw  through  the  great  trochanter  along  the 
neck  into  the  head,  while  the  fragments  are  adjusted  by  extension ;  the 
nail  is  removed  after  a  month  and  the  case  treated  as  before  with  plaster- 
spica  or  Thomas's  calliper  splint. 

(2)  Fractukes  of  the  Neck  near  its  Base  (partially  extracapsular). 
In  these  cases  the  line  of  fracture  runs  into  the  joint  in  front  on  account  of 
the  fact  that  the  latter  includes  the  whole  neck  to  the  anterior  intertrochan- 
teric line  in  front,  while  behind  the  fracture  is  quite  extracapsular.  These 
injuries  are  nearly  always  caused  by  considerable  violence,  such  as  heavy 
falls  on  the  trochanter  or  crushes  between  buffers.  They  are  most  usual 
in  adult  life,  and  as  a  result  of  the  great  violence  are  often  impacted  or 
comminuted. 

Signs.  These  are  similar  to  those  of  the  last  variety,  but  the  shortening 
of  the  limb  and  the  displacement  of  the  trochanter  upwards  are  more  marked, 
the  former  amounting  (unless  impaction  occurs)  to  two  or  more  inches ; 
morover,  the  trochanter  is  displaced  further  inwards  (bi-trochanteric  test), 
and  when  the  thigh  is  rotated  the  excursion  of  the  trochanter  is  diminished 
still  further  than  in  the  former  condition. 

Diagnosis  is  not  difficult  unless  impaction  has  taken  place,  but  radio- 
graphs are  always  advisable  to  settle  the  exact  point  of  fracture. 

Treatment.  The  application  of  Liston's  long  splint  and  weight-extension 
up  to  about  twelve  pounds  will  generally  reduce  the  fragments  and  prevent 
shortening.  The  limb  should  be  kept  in  this  apparatus  six  to  seven  weeks, 
and  then  the  patient  can  get  about  in  a  plaster-spica  and  crutches,  or, 
better,  in  a  Thomas's  calliper  knee-splint,  no  weight  being  placed  on  the  foot 
for  four  months.  Impacted  fractures  should  not,  as  a  rule,  be  broken  down 
if  the  shortening  is  less  than  an  inch,  the  limb  being  simply  steadied  on  a 
long  splint.  Should  the  shortening  be  greater  than  this  and  the  patient  of 
good  physique,  the  fracture  should  be  disimpacted  and  extension  employed 
as  in  ordinary  fractures.  When  occurring  in  young  persons  every  care 
should  be  taken  to  secure  good  reposition  of  the  fragments,  by  open  opera- 
tion if  necessary,  if  there  is  not  so  much  comminution  as  to  render  the 
possibility  of  this  unlikely. 

(3)  Fractures  between  the  Trochanters  (pertrochanteric).  This 
lesion  is  due  to  similar  violence  to  that  causing  the  last  group  :  comminution 
is  not  uncommon.  The  signs  and  displacement  are  very  similar  to  the  last 
type  except  that  the  tip  of  the  great  trochanter  can  be  felt  in  a  practically 
normal  position  and  it  does  not  move  when  the  leg  is  rotated  from  the  foot. 

Treatment.  The  long  splint  and  extension  may  be  employed  here  also, 
followed  in  six  weeks  by  a  plaster-spica  or  calliper  splint.  But  if  the  frag- 
ments are  not  in  satisfactory  position  open  operation  should  be  done  within 
ten  days  of  the  injury,  since  this  position  is  readily  accessible  for  securing 
good  position  with  a  plate.  The  treatment  of  all  these  cases  should  be 
carefully  controlled  by  X-ray  examinations. 


316 


A  TEXTBOOK  OF  SURGERY 


(4)  Separation  ov  the  Great  Trochanter.  Tins  may  take  place  as  a 
separation  of  the  trochanteric  epiphysis  or  after  the  latter  has  united  with 
the  shaft,  i.e.  after  eighteen  years. 

The  cause  is  always  duvet  violence  to  the  trochanter.  Separation  of 
the  smaller  fragment  may  be  slight  or,  if  the  aponeurosis  is  torn,  considerable. 

Signs.  In  addition  to  bruising  and  effu- 
sion the  trochanter  will  be  movable  on  the 
shaft  with  crepitus,  and  a  gap  may  be  felt. 

Treatment.  Where  there  is  no  separa- 
tion the  leg  may  be  steadied  on  a  long 
splint  for  a  month,  massage  being  carried 
out  from  the  first. 

If  there  is  marked  separation  of  the 
trochanter  it  should  be  exposed  by  turning 
up  a  skin-flap  and  fixing  with  screw  or  peg. 

(5)  Separation   of   the  Epiphysis  of 
the  Head.     This  injury  occurs  in  patients 
under  twenty  and   is  more  frequent  than 
was  supposed  before  the  use  of  X-rays  made 
it  well  known,   and  is   of  considerable    im- 
portance, since,  if  neglected,  this  separation 
leads   to   the   deformity  known    as    "  coxa 
vara  "  or  diminution  of  the  angle  of  the  neck 
of  the  femur,  with  loss  of  ability  to  abduct 
and  considerable  shortening   of   the   limb, 
which  occasion  awkward   limping.     Indeed 
this   injury   is   one    of   the   more 
important  causes  of  "  coxa  vara." 
Causes.    Like  fractures  of  the 
inner  part  of  the  neck,  this  lesion 
is  due  to  relatively  slight  violence, 
such  as  slipping,  tripping,  &c. 
Displacement.     This  is  often  incomplete  ;  in  any  case  the  neck  is  displaced 
upwards  on  the  epiphysis  of  the  head. 

Signs.  The  patient  can  often  walk,  but  does  this  with  a  painful  limp 
(the  injury  being  often  mistaken  for  a  sprain).  On  examination  tin1  limb 
is  found  to  be  everted  on  the  injured  side,  to  be  shortened  in  varying  degree, 
according  to  the  amount  of  displacement  present,  while  abduction  of  the 
thigh  is  always  greatly  impaired.  There  will  be  in  addition  a  painful, 
tender  swelling  aboul  the  joint  which  distinguishes  the  lesion  from  cases  of 
vara  of  old  standing. 
Treatment.  In  cases  of  partial  separation,  which  is  the  usual  condition, 
extension  in  the  abducted  position  may  be  employed.  The  abduction 
box-splint  is  useful  for  this,  and  consists  of  a  box-splint,  one  side  of  which 
is  at  right  angles  with  the  foot-board,  the  other  hinged  opposite  the  hip 
so  that  it  can  he  abducted,  while  the  end  or  foot-board  of  the  box  is  elon- 


FlG.  126.    Abduction  box-splint. 
(Openshaw.) 


SEPARATION  OF  THE  UPPER  FEMORAL  EPIPHYSIS       317 


gated  toward  the  hinged  side  and  has  a  row  of  holes  in  it  so  that  the  abducted 
part  can  be  fixed,  in  the  required  position  of  abduction,  by  means  of  a  peg. 
Finally,  the  part  of  the  splint  above  the  abduction  hinge  which  lies  against 
the  body  is  fixed  to  the  straight  side  of  the  splint  opposite  by  two  angled 
iron  bars  which  clear  the  chest  of  the  patient  and  at  the  same  time  are  of 
adjustable  length,  so  that  the  two  sides 
fit  snugly  the  bodies  of  patients  of 
varying  size. 

The  limb  is  placed  in  this  splint, 
abducted  to  about  thirty  degrees — 
extension  being  made  as  usual,  with 
strapping  stirrup  and  weight.  Radio- 
graphs are  taken  after  three  days  and 
the  weight  increased  if  necessary.  The 
limb  should  be  in  this  position  two 
months,  till  union  is  fairly  good  ;  and 
then  a  Thomas's  knee-splint  or  calliper 
splint  should  be  worn  for  three  months 
to  prevent  the  weight  of  the  limb  caus- 
ing the  deformity  to  recur. 

Whitman's  method  of  full  abduction 
and  placing  in  a  long  plaster-spica  from 
ankle  to  costal  margin  is  perhaps  even 
better.  Where  separation  is  consider- 
able and  abduction  fails  to  reduce 
deformity  open  operation  should  be 
done  by  anterior  incision,  the  frag- 
ments reduced,  and  the  limb  put  up  in 
full  abduction  in  a  long  plaster-spica  as 
advocated  by  Whitman. 

(c)  FRACTURES  OF  THE  SHAFT 
OF  THE  FEMUR 


Fig.    127.     The  lower  limb   put   up  in 

abduction  in  plaster,  for  separation  of 

the     upper     epiphysis     of     the     femur. 

(Whitman.) 


Anatomy.  The  femur  in  this  region 
is  deeply  situated  and  well  surrounded 
by  muscles,  rendering  palpation  diffi- 
cult   and    accurate    localization    of    a 

fracture  and  the  exact  position  of  fragments  uncertain  without  the  help  of 
X-rays.  The  deep  situation  of  the  bone  renders  splint  treatment,  unless 
assisted  by  extension,  of  little  use,  while  the  ends  of  fragments  are  readily 
caught  in  the  surrounding  muscles,  rendering  operation  more  necessary 
in  the  femur  than  in  any  other  long  bone.  Fractures  may  be  found  at 
any  point  in  the  length  of  the  shaft,  but  for  purposes  of  description  may  be 
divided  into  (1)  those  of  the  upper,  (2)  of  the  middle,  and  (3)  of  the  lower 
part  of  the  shaft. 

(1)  Fractures  in  the  Upper  part  of  the  Shaft  of  the  Femur  are 


3 1 8 


\  TKXTliOOK  OF  Sl'KdKRY 


more  usual  in  adults  ;  in  children  they  arc  more  often  towards  the  middle, 
while  in  the  aged  the  Deck  is  the  main  seal  of  lesion. 

Fractures  here  may  he  due  to  direct  or  indirect  violence,  and  the  line 
of  fracture  may  be  transverse  or  oblique  ;  the  upper  fragment  is  flexed  and 
abducted  by  the  psoas  and  muscles  inserted  into  the  great  trochanter,  while 
the  lower  fragment  is  drawn  up  to  the  inner  side  of  this  by  the  long  muscles 
running  from  the  pelvis  to  the  tibia,  viz.  the  hamstrings  and  rectus  femoris. 

N  ns.  Shortening  and  eversion  of  the  limb  with  abnormal  mobility 
at  the  place  of  fracture  and  crepitus,  unless  the  fragments  are  imbedded 


Fig.  128 


Application  of  Hodgen's  wire-splint  for  fracture  of  the  femur; 
small  inset  shows  the  tilting  of  the  lower  end  of  the  bed. 


in  muscle,  will  render  diagnosis  easy.  The  lower  end  of  the  upper  fragment 
can  often  be  felt  on  the  antero-exterior  aspect  of  the  thigh. 

Treatment.  As  the  upper  fragment  is  so  short  that  it  cannot  be  con- 
trolled by  any  sort  of  splint,  it  follows  that  the  lower  fragment  must  be 
brought  into  line  with  the  upper.  In  other  words,  the  thigh  must  be  in  a 
position  of  flexion  and  abduction,  while  at  the  same  time  extension  is 
applied. 

This  can  sometimes  be  managed  in  adults  by  the  use  of  Hodgen's  splint, 
which  is  an  oblong  wire  frame  slightly  bent  at  the  knee.  The  limb  is  fastened 
to  the  lower  end  of  this  by  the  usual  stirrup-extension  and  cord,  and  is  pre- 
vented from  falling  through  the  frame  completely  by  several  strips  of  flannel 
which  pass  across  from  side  to  side  of  the  frame  under  the  limb.   (Fig.  128.) 

The  frame  containing  the  limb  slung  on  these  strips  and  fixed  with  the 
extension,  is  hung  to  an  adjustable  cross-bar  seven  feet  high  at  the  foot 
of  the  bed  in  an  abducted  and  flexed  position,  the  foot  of  the  bed  being 
tilted  to  prevent  the  patient  from  being  drawn  down  by  the  drag  thus 
exercised  on  the  limb.     In  children  the  ordinary  box-splint  with  extension 


FRACTURES  IN  THE  SHAFT  OF  THE  FEMUR  319 

of  the  injured  limb  may  be  employed,  or  the  box-splint  with  flexion  of  the 
limb  at  the  hip  suggested  by  Walton.  The  box-splint  consists  of  two 
Liston's  long  splints  joined  at  the  bottom  by  a  foot-board  whose  length  is 
the  width  of  the  patient ;  the  three  together  form  three  sides  of  a  shallow 
box.  The  limbs  are  bandaged  to  each  of  the  long  side  splints,  while  a  hole 
through  the  foot-piece  opposite  the  foot  on  the  injured  side  takes  the  cord 
from  the  stirrup- extension,  which  then  passes  over  a  pulley.  The  box-splint 
is  better  for  children  as  it  gives  more  control  of  a  wriggling  patient.  (Fig.  125.) 
In  cases,  however,  where  there  is  much  flexion  of  the  upper  fragment 
the  following  modification  is  better  (Walton).     This  consists  of  a  box- 


Fig.  129.     Box-splint  modified  so  that  extension  of  the  lower  can  be  maintained 
with  the  thigh  flexed.     (After  Walton. ) 

splint  unpadded  in  the  part  below  the  hip,  and  inside  this  a  second  box 
capable  of  moving  in  a  vertical  plane  about  a  pivot  opposite  each  hip.  The 
inner  "  box  "  is  padded  and  can  be  retained  at  a  suitable  angle  by  a  ratchet 
arrangement.   (Fig.  129.) 

This  is  applied  as  a  box-splint  :  both  thighs  are  flexed  at  the  hip,  the 
pulley  over  which  the  extension- cord  runs  being  at  the  level  with  the  distal 
elevated  end  of  the  inner  part  of  the  box.  Thus  extension  is  made  with  a 
flexed  hip  and  the  patient  is  as  well  controlled  as  in  a  box-splint. 

It  will  be  noted  that  this  arrangement  is  little  different  from  the  gallows 
splint  of  Bryant,  but  allows  flexion  of  the  thigh  to  any  angle  required  and 
not  merely  to  a  right  angle  as  in  the  latter.   (Fig.  130.) 

Radiographs  should  be  taken  during  the  first  few  days  and  the  direction 
and  power  of  the  extension  altered  till  good  position  is  attained ;  if  this 
cannot  be  managed  in  ten  days  by  this  plan,  there  is  little  use  in  persisting, 
but  operative  measures  should  be  undertaken.  These  are  fairly  often  needed 
in  fractures  of  the  femur,  especially  at  the  upper  end  of  the  shaft  and  in 
adults.     The  fracture  should  be  exposed  by  a  long  incision  at  the  outer  side 


A  TEXTBOOK  OF  SURGERY 


of  the  thigh  and  the  fragments  extricated  from  the  muscles,  where  they 
are  usually  imbedded,  and  fixed  in  good  position   with  plates  or  wires, 
ding  tu  the  direction  <>l'  tin-  line  of  fracture.   (Figs.  125,  128.) 
Where  splinting  and  extension  arc  successful  union  will  be  tolerably  firm 

in  adults  in  six  or  seven  weeks,  in  children  in  three  or  four  :  the  best  plan 
is  to  remove  the  splint  at  about  this  time  and  keep  the  patient  in  bed, 
allowing  active  movements  and  practising  massage  and  passive  movements 
df  the  hi])  and  knee.  Children  may  be  allowed  up  a  week  later,  adults  in 
two  or  three  weeks,  using  crutches  and  not  placing  much  weight  on  the 
limb  for  another  month.  After-treatment  with 
plasters  should  be  avoided  if  possible,  but  the  neces- 
sity of  getting  patients  out  of  hospital  renders  the 
use  of  a  plaster-spica  essential  in  many  cases  for  a 
month  or  six  weeks  after  the  splint  is  removed,  and 
this  will  render  a  longer  course  of  massage  needed  to 
restore  the  limb  to  its  proper  vigour. 

(2)  Fractures  of  the  Middle  of  the  Shaft 
of  the  Femur.  The  line  of  fracture  is  usually 
oblique  and  the  displacement  chiefly  in  the  direction 
of  shortening,  being  caused  by  the  long  muscles  of 
the  thigh.  There  may  be  some  tilting  of  the  upper 
fragment  by  the  psoas  or  of  the  lower  by  the 
gastrocnemius  as  in  supracondylar  fractures,  but 
these  displacements  are  usually  trifling. 

Signs.  Shortening  and  mobility  with  crepitus  if 
the  fragments  are  not  embedded  in  muscle. 

Treatment.  In  children  extension  in  a  box-splint 
gives  excellent  results  ;  in  adults  extension  on  Liston's 
long  splint  is  apt  to  cause  bowing-out  of  the  thigh, 
and  it  is  better,  therefore,  to  employ  extension  with 
Hodgen's  splint,  care  being  taken  to  control  the 
effects  of  this  with  radiographs,  and  if  the  result  is  not 
satisfactory  after  altering  the  splint  and  increasing 
the  extension-weight,  open  operation  should  be  employed.  This  will  often 
be  needed  in  adults  but  seldom  in  children.  The  latter  require  about  four 
and  adults  about  six  weeks  on  the  splint,  after-treatment  being  similar  to 
that  for  fractures  of  the  upper  third.  A  useful  method  for  children  is 
su,LfLr<'sted  by  Robert  Jones  :  a  stirrup-extension  is  placed  on  the  leg 
and  thigh  and  made  fast  to  the  lower  bar  of  a  Thomas's  knee-splint,  the 
upper  part  of  which  forms  a  good  point  of  counter-extension  against  the 
tuber  ischii. 

(."»)  Fractures  of  the  Lower  Third  of  the  Femur.  The  causes  and 
signs  are  similar  to  the  last  variety  except  that  the  lower  fragment  is  apt 
to  be  tilted  backwards  to  a  greater  degree  by  the  gastrocnemius. 

Treatnu  nt.  Where  the  displacement  is  not  great,  extension  with  Hodgen's 
splint  will  be  good,  but  if  there  is  much  tilting  of  the  lower  fragment  the 


FlG.  130.  Principle  of 
the  gallows  -  splint  or 
weight-extension  of  the 
legs  with  the  thighs 
flexed  to  a  right  angle. 


THE  KXEE- JOINT  321 

knee  must  be  flexed.  This  may  sometimes  be  achieved  by  splinting  with 
McTntyre's  splint,  which  consists  of  a  double-inclined  gutter  splint,  one 
section  fitting  the  thigh,  the  other  the  leg,  while  a  foot-piece  effectively 
prevents  foot-drop.  (Fig.  137,  p.  336.)  The  angle  of  flexion  of  the  knee 
can  be  altered  by  a  double  screw  and  nut.  It  may  be  necessary  to  flex 
the  knee  to  a  right  angle  or  less  to  reduce  the  displacement.  Should  X-ray 
examination  show  unsatisfactory  position,  which  is  not  unusual,  open 
operation  should  be  done  and  the  fragments  united  by  plates  or  wire. 

(d)  INJURIES   ABOUT    THE   KNEE-JOINT 

The  following  are  described  : 

(1)  Fractures  of  the  lower  end  of  the  femur  ;  (2)  fractures  of  the  upper 
end  of  the  tibia  ;  (3)  fractures  of  the  patella  ;  (-4)  dislocations  and  derange- 
ments of  the  knee-joint,  including  injuries  to  muscles,  tendons,  and  bursas 
about  the  knee. 

Anatomy.  This  joint  owes  its  great  strength  entirely  to  its  ligaments, 
the  bony  surfaces  being  but  poorly  coapted.  Of  these  ligaments  the  crucial, 
the  posterior  (strengthened  by  the  insertion  of  the  semi-membranosus  tendon), 
the  internal  lateral,  and  the  ligamentum  patella?  are  of  great  strength,  and 
if  overstretched  are  likely  to  tear  away  their  bony  attachments  rather  than 
to  rupture. 

Bony  Landmarks.  The  condyles  of  the  femur  can  be  felt  in  their  entirety 
when  the  knee  is  flexed.  The  inner  can  be  traced  up  to  the  adductor  tubercle, 
which  marks  the  position  of  the  epiphyseal  line.  The  patella  can  be  readily 
palpated  and  is  movable  when  the  leg  is  passively  extended,  fixed  when 
the  knee  is  flexed  or  actively  extended.  The  ligamentum  patellae  are  clearly 
defined  when  the  knee  is  flexed  and  lead  down  to  the  tubercle  of  the  tibia, 
on  either  side  of  which  are  the  tuberosities  of  the  tibia,  which  are  just  below 
the  condyles  in  extension  of  the  knee  but  behind  them  in  acute  flexion  of 
the  joint.  Behind  and  external  to  the  external  tuberosity  is  the  head  of  the 
fibula,  which  is  below  and  behind  the  outer  condyle  in  extension  but  above 
and  behind  it  in  acute  flexion.  One  inch  below  the  head  of  the  fibula  the 
latter  is  crossed  by  the  external  popliteal  nerve. 

Between  the  condyles  and  the  tuberosities  the  semilunar  cartilages  can 
be  obscurely  felt. 

(1)  Fractures  of  the  Lower  End  of  the  Femur.  The  following  are 
described :  The  supracondylar,  the  T-shaped,  separation  of  the  lower 
epiphysis  of  the  femur,  separation  of  either  condyle. 

(a)  The  Supracondylar  Fracture.  This  may  be  due  to  falls  on  the  knee 
or  direct  violence. 

Displacement.  The  lower  fragment  is  rotated  and  displaced  backward 
by  the  gastrocnemius. 

Signs.  Shortening,  unnatural  mobility,  and  crepitus.  If  the  lower 
fragment  is  much  flexed  by  the  gastrocnemius,  there  will  be  groat  deformity 
and  the  leg  may  be  anaemic  and  pulseless,  or  cyanosed  and  congested  from 
pressure  on  the  vessels  by  this  fragment. 

X  21 


A    I  KXI  BOOK  OF  SURGERY 


Ti  Acute  flexion  of  the  knee-joint  may  reduce  the  fragments. 

Should  this  fail  open  operation  will  be  needed,  and  if  there  are  signs  of 
rare  on  the  vessels  this  operative  treatment  will  be  urgent.    The  frag- 
ment may  be  fixed  with  plate  01  screw. 

(l>)  The  T-snaped  fracture  is  due  to  crushing  violence  such  as  falls  on 
the  bent  knee,  when  the  patellse  may  act  asa  wedge  and  drive  the  condyles 
apart  ;    we  have  Found  this  lesion  in  both  knees  of  one  patient  apparently 

from  this  cause.  Displacement  consists  in 
separation  of  the  fragments  and  semi-rotation 
backward  by  the  gastrocnemius. 

Signs.  The  knee  is  much  widened,  there  is 
gross  effusion  into  the  joint;  mobility  of  the 
fragments  on  each  other  and  on  the  shaft,  with 
crepitus,  is  noted. 

Treatment.  In  these  severe  injuries  open 
operation  as  a  rule  gives  the  only  hope  of  a 
reasonably  successful  result ;  the  fracture  may 
be  exposed  by  an  incision  on  the  outer  side. 
the  joint  opened  ;  the  lower  fragments  are  care- 
fully brought  into  apposition  so  that  the  carti- 
lage-covered surface  is  in  perfect  alignment  and 
united  by  a  long  screw  passing  deep  into  the 
cancellous  bone.  The  reconstructed  lower  frag- 
ment is  then  united  with  the  rest  of  the  shaft 
by  plate  and  screws,  or,  if  running  obliquely,  a 
surrounding  wire  may  take  the  place  of  some  of 
the  screws  as  there  is  some  chance  of  additional 
screws  splitting  the  already  comminuted  lower 
fragment. — Note.  As  in  the  last  variety,  signs 
of  pressure  on  the  vessels  indicate  the  need  for 
immediate  operation. 

(c)  Fractures    of    either    condyle    are    due 

to    falls    on    the    knee    or    severe    crushes    or 

wrenches  of   the  joint ;    in  the  latter  instance 

the  condyle,  usually  the  internal,  is  torn  off  by  overstretching  the  internal. 

lateral  ligament. 

ins.  The  joint  is  distended  with  blood  and  the  leg  usually  deviates 
to  the  side  of  the  fracture  ;  there  is  no  shortening,  but  the  condyle  can  be 
moved  on  the  rest  of  the  bone,  and  crepitus  is  noted,  while  further  the  ex- 
tended leg  can  be  ab-  or  adducted  to  the  side  of  fracture  (normally,  of  course, 
there  is  no  lateral  movement  possible  in  extension). 

Treatment.    The  deformity  can  sometimes  be  reduced  by  flexing  the 
and  manipulating  the  fragment  and  then  placing  in  full  flexion.  Radio- 
graphs should  be  always  taken,  and  if  the  position  is  not  strictly  accurate, 
as  will  usually  be  the  case,  the  fragments  should  be  exposed  by  open  operation 
and  fixed  with  long  screws. 


Fiq   131.    Separation  of  lower 
epiphysis  of  the  femur,  show- 
ing direction  of  violence  which 
causes  the  displacement. 


LOWER  ^EPIPHYSIS  OF  THE  FEMUR  323 

(d)  Separation  of  the  Lower  Epiphysis  of  the  Femur.  This  can  only  occur 
before  twenty-five,  and  is  usually  due  to  violent  hyperextension  of  the  leg. 
The  classical  method  of  producing  this  lesion  is  for  a  boy  to  hang  behind 
a  cab  and  entangle  his  leg  in  a  revolving  hind- wheel ;  violent  hyper- 
extension and  traction  are  thus  made  on  the  leg,  and  we  have  even  known 
a  leg  torn  completely  off  by  this  accident,  the  separation  taking  place  at 
the  epiphyseal  Hue. 

Displacetnent.  Owing  to  the  direction  of  the  force,  the  epiphysis  is  dis- 
placed forwards  and  at  the  same  time  rotated  backward  by  the  attached  gas- 
trocnemius ;  the  lower  end  of  the  diaphysis  may  press  on  the  popliteal  vessels. 

Diagnosis  may  not  be  easy  owing  to  the  great  amount  of  swelling.  Dis- 
placement of  the  whole  leg  forwards  on  the  femur,  while  the  condyles  are 
in  normal  relation  to  the  upper  end  of  the  tibia,  found  in  a  boy  will  suggest 


Fie  132.     Acute  flexion  of  the  knee  for  separation  of  the  lower  epiphysis 
of  the  femur. 

the  diagnosis,  and  if  he  has  been  riding  behind  a  cab  this  will  almost  be  a 
certainty  ;  but  often  a  radiograph  is  needed  to  confirm  the  diagnosis. 

Treatment.  Anaesthesia  is  essential.  Steady  traction  is  made  on  the 
leg  by  an  assistant,  while  the  surgeon,  clasping  his  hands  under  the  lower 
end  of  the  femoral  diaphysis,  pulls  this  up  and  so  gradually  flexes  the  knee 
till  both  hip  and  knee  are  fully  flexed,  traction  all  the  time  being  maintained 
on  the  leg.  In  this  manner  the  epiphysis  is  brought  round  from  its  position 
on  the  anterior  surface  of  the  diaphysis  to  its  proper  place  ;  the  knee  is  then 
kept  acutely  flexed,  i.e.  at  about  sixty  degrees  (Hutchinson).  Should  this 
manoeuvre  fail,  it  will  be  necessary  to  explore  the  part  by  incision  and  lever 
the  epiphysis  back  into  position. 

In  all  these  lesions  involving  the  knee-joint  passive  movements  should 
be  commenced  early,  i.e.  within  ten  days  if  possible.  This  is  a  great  argu- 
ment in  favour  of  operative  treatment ;  in  nearly  all  cases,  indeed>  with 
the  exception  of  separations  of  the  lower  epiphysis,  open  operative  treatment 
is  probably  the  method  of  election. 

(2)  Fractures  of  the  Upper  Exd  of  the  Tibia.  The  following 
fractures  are  found  here  :  fracture  of  either  tuberosity,  fracture  of  the  spine, 
separation  of  the  upper  epiphysis. 


324  A  TEXTBOOK  OF  SURGERY 

(a)  Fractures  of  the  tuberosities  are  generally  due  to  direcl  violence, 
but  may  be  caused  by  falls  on  the  feet,  the  tuberosities  being  driven  off  by 
impact  with  the  condyles  of  the  femur  or  wrenched  off  in  twists  of  the 
knee  by  ever-stretching  of  the  ligaments;  at  any  rate  this  may  happen 
to  the  inner  tuberosity. 

Signs.  The  knee-joint,  being  always  involved,  will  be  distended  with 
blood  and  appear  widened  ;  movement  of  one  or  both  tuberosities  with 
crepitus  can  be  made  out  in  some  cases,  though  owing  to  the  distension 
of  the  joint  this  may  not  be  easy  ;  lateral  mobility  of  the  extended  leg 
will  also  be  found.  Exact  diagnosis  will  often  require  radiographic  investi- 
gation. 

Treat  mi  at.  In  some  instances  reduction  will  be  easy  and  the  position  of 
the  fragments  good  if  the  knee  be  well  flexed  ;  more  often,  however,  it  will 
be  necessary  to  expose  the  fragments,  opening  the  joint,  and  securing  accurate 
alignment  by  fixing  the  separated  fragment  with  a  screw.  If  both  tubero- 
sities are  broken  off  it  will  generally  suffice  to  fix  these  together  with  a  screw  ; 
once  reduced  the  irregularity  of  the  fragments  will  prevent  these  moving 
« m  the  shaft  of  the  tibia,  especially  if  put  up  in  flexion  on  a  Mclntyre's  splint, 
but  if  it  seems  necessary  a  plate  may  be  used  in  addition. 

Should  the  fragments  be  impacted,  they  are  best  left  in  this  condition 
unless  deformity  be  great,  when  recourse  should  be  made  to  open  operation. 

If  splints  alone  are  used  passive  movements  may  be  started  in  fourteen 
days,  but  after  open  operation  only  a  week  need  elapse  before  they  are 
commenced. 

(b)  Fracture  of  the  Spine  of  the  Tibia.  This  is  an  uncommon  lesion  and 
is  due  to  violent  wrenches  of  the  joint,  the  spine  either  being  knocked  off  by 
impact  of  the  inner  surface  of  one  of  the  condyles  or  pulled  off  by  the  over- 
stretching of  one  of  the  crucial  ligaments,  as  may  happen  in  dislocations  or 
subluxation  of  the  knee. 

Diagnosis  can  only  be  made  by  X-rays  or  exploration.  There  is  effusion 
of  the  joint,  a  tendency  to  lock  in  semi-flexion,  suggesting  internal 
derangement,  and  subluxation  of  the  tibia  backward  or  forward  on  the  femur. 

Treatment.  The  joint  should  be  opened  by  a  vertical  incision  over  its 
inner  anterior  aspect,  as  for  removing  the  internal  semilunar  cartilage. 
The  fragment  broken  off  the  spine  should  be  dissected  out  of  the  crucial 
ligaments  and  the  latter,  if  possible,  sutured  into  place  ;  massage  and  move- 
ments may  be  commenced  in  a  week,  followed  by  a  prolonged  course  of 
exercise,  such  as  cycling  or  rowing  on  a  sliding  seat,  to  strengthen  the  muscles 
acting  on  the  knee  without  causing  any  twisting  of  the  joint,  but  simply 
extension  and  flexion. 

(c)  Separation  of  the  Upper  Epiphysis  of  the  Tibia.  Separation  of  this 
epiphysis,  which  joins  the  shaft  at  twenty-four  and  includes  not  only  the 
tuberosities  but  also  the  tubercle  of  the  tibia,  is  less  common  than  that 
of  the  lower  end  of  the  femur  because  of  the  strong  expansions  of  the  internal 
lateral  ligament  and  ligamentum  patellse  (which  fix  the  epiphysis  firmly 
to  the  shaft),  and  is  caused  by  violent  wrenches  of  the  leg  at  the  knee. 


SEPARATION  OF  THE  UPPER  TIBIAL  EPIPHYSIS 


325 


The  separation  is  forward  and  usually  incomplete  ;  the  most  usual 
condition  met  with  is  that  described  by  Schlatter  and  known  as  Schlatter's 
disease.  In  this  lesion  the  lappet  of  the  epiphysis  forming  the  tubercle  of 
the  tibia  is  separated  from  the  shaft  by  powerful  traction  of  the  quadriceps 
femoris. 

Signs.  Separation  of  the  whole  upper  epiphysis  of  the  tibia  can  hardly 
be  distinguished  from  fractures  of  the  upper  end  of  the  bone  except  on 
consideration  of  the  patient's  age  and  the  use  of  radiographs.  Partial 
separation  (Schlatter)  may  be  suspected  when  a  boy  has  a  tender  swelling 


Fig.   133.     A.  Partial  avulsion  of  the  anterior  part  of  the  epiphysis  of  the  tibia 
(.Schlatter's  disease).-    15.  Ossification  of  the  tubercle  of  the  upper  end  of  the  tibia 

from  two  centres. 


of  the  tubercle  of  the  tibia  and  pain  in  forcibly  extending  the  leg,  e.g.  on 
walking  upstairs.  On  examination  with  X-rays  there  will  be  noted  a  spot 
of  rarefaction  of  the  bone  under  the  downward-extending  lappet  of  the 
epiphysis,  which  is  sometimes  considered  to  be  a  tuberculous  focus ;  as, 
however,  this  practically  always  heals  under  suitable  treatment  without 
sinus  formation,  it  is  questionable  whether  the  tubercle  bacillus  is  often. 
if  ever,  to  blame,  at  the  same  time  this  is  a  typical  juxta-epiphyseal 
strain  and  might  be  easily  imagined  to  be  the  originating  point  of  a  tuber- 
culous infection. 

Treatment.  The  complete  variety  is  reduced  under  anaesthesia  by  flexion 
of  the  knee,  followed  by  maintaining  the  joint  in  this  position  for  three 
weeks,  after  which  massage  and  movements  may  be  initiated. 

The  incomplete  variety  is  best  treated  by  the  use  of  a  Thomas's  knee- 
splint,  to  prevent  action  of  the  extensors  of  the  leg  for  three  months  or 


\    I KYI BOOK  OF  SURGERY 

more,  till  the  pain3  Bwelling,  and  tenderness  are  gone  and  the  separation 
presumably  united,  when  walking  is  gradually  resumed  at  first  on  the  level, 
walking  upstairs  being  resumed  very  gradually. 

(3)  Fractures  of  the  Patella.  Two  very  distinct  types  of  fracture 
are  noted  here,  according  as  the  lesion  is  due  to  direct  or  indirect 
violence. 

(n)  When  due  to  direct  violence,  e.g.  a  fall  or  heavy  blow  on  the  knee- 
cap, the  hone  is  shattered  usually  in  a  stellate  manner  and  there  is  no 
separation  of  the  fragments,  since  the  aponeurotic  covering  keeps  them  in 
position. 

n  >\  Bruising  and  tenderness  of  the  patella  with  some  effusion  into 
the  joint  are  the  only  signs,  as  a  rule;  movement  of  the  fragments  and 
crepitus  are  seldom  noted  and  the  power  of  extension  of  the  leg  is  often 
considerable,  so  that  walking  is  moderate.  Often  X-rays  are  needed  to 
make  the  diagnosis. 

Treatment.  Pressure  by  strapping  or  bandaging  over  wool  to  remove 
effusion,  followed  by  massage,  passive  and  active  movements,  are  all  that 
is  necessary  in  most  cases.  Operative  measures  are  only  requisite  in  those 
rare  cases  where  there  is  separation  of  the  fragments. 

(b)  "When  due  to  indirect  violence  the  injury  is  caused  by  rapid  and 
forcible  extension  of  the  semiflexed  knee  against  resistance.  In  this  position 
the  patella  rests  with  its  central  part  against  the  articular  surface  of  the 
femur.  The  sudden  strong  pull  of  the  quadriceps  snaps  the  patella  across 
tin'  lower  end  of  the  femur,  which  acts  as  a  fulcrum.  Such  sudden  exten- 
sions of  the  leg  are  made  in  efforts  to  maintain  the  balance  after  a  slip  or 
stumble.  e.g.  when  falling  forwards  or  backwards  with  a  weight  on  the  back. 
The  bone  generally  gives  way  near  the  centre,  but  the  lower  fragment  is 
often  the  smaller  and  sometimes  very  much  smaller  than  the  upper. 

Displacement  Unless  the  aponeurosis  of  the  quadriceps,  which  covers 
the  bone,  is  untorn,  which  is  unusual,  separation  of  the  fragments  will  take 
place,  becoming  greater  the  longer  the  condition  persists,  finally  amounting 
to  several  inches.  Besides  longitudinal  displacement  there  is  nearly  always 
some  rotation  of  the  fragments  transversely.  The  lower  fragment  is  com- 
monly tilted  so  that  its  cartilage-covered  surface  faces  upwards  and  the 
fractured  surface  forwards  ;  in  addition  the  aponeurosis  is  usually  turned 
in  over  the  fractured  surfaces. 

Signs.  There  is  complete  inability  to  extend  the  leg  at  the  knee,  and 
walking  is  consequently  impossible.  The  knee-joint  is  distended  with  blood, 
and  on  palpation  a  distinct  gap  of  about  an  inch  will  lie  felt  between  the 
fragments,  gradually  increasing  from  the  tension  of  the  quadriceps.  The 
fragments  will  naturally  be  movable  on  each  other. 

Owing  to  the  great  displacement  of  the  fragments,  the  tilting  so  that 
the  cartilage  of  one  fragment  is  apposed  to  fractured  surface  of  the  other 
and  the  interposition  of  aponeurosis  between  the  fragments,  bony  union 
can  hardly  occur  by  any  method  of  splinting.  Union  of  the  fracture  under 
such   treatment   is  always  fibrous  and  the  separation  of  the  fragments 


SEPARATION  OF  THE  UPPER  TIBIAL  EPIPHYSIS        327 

gradually  increases.  Such  a  limb  is  never  strong,  though  useful  enough  for 
walking  about,  and  may  give  a  result  sufficiently  good  for  old  persons  or 
those  whose  occupations  are  not  laborious  or  active. 

Treatment.  The  only  method  by  which  bony  union  (and  no  further 
separation)  can  be  guaranteed  is  by  open  operation  and  wiring  or 
plating. 

The  importance  of  bony  union  to  restore  the  joint  to  its  former  strength 
cannot  be  insisted  upon  too  strongly ;  therefore,  unless  important  contra- 
indications are  present,  operative  treatment  should  always  be  advised. 
Such  contra-indications  are  :  (1)  An  infected  condition  of  the  skin  of  the 
part,  e.g.  intractable  eczema  ;  (2)  severe  constitutional  disease,  such  as 
renal  disease,  diabetes,  &c.  ;    (3)  debility ;    (4)  old  age,  &c. 

(1)  Where  operative  treatment  is  contra-indicated  the  patient  should 
lie  on  his  back  with  the  lower  limb  on  an  inclined  plane  to  relax  the  rectus 


Fig.   134.     Fibrous  union  of  fractures  of  the  patella  with  lengthening. 

femoris.  It  is  doubtful  whether  the  usual  attempt  to  bring  down  the 
upper  fragment,  by  fixing  a  U-shaped  piece  of  strapping  over  it  with  circular 
strips,  and  fixing  this  to  the  foot-piece  of  the  splint  with  rubber  tractors, 
is  of  any  use.  The  results  are  just  as  good  if  massage  alone  be  used,  in 
addition  to  the  flexed  position  of  the  thigh .  After  three  weeks  on  the  inclined 
plane  the  patient  should  be  allowed  to  get  about  gradually,  wearing  a 
leather  knee-cap  which  is  cut  out  in  front  to  receive  the  patella  and  laces 
at  the  side,  having  an  adjustable  hinge  which  permits  no  flexion  of  the  knee 
at  first  but  later  can  allow  increasing  amounts.  Fibrous  union  alone  can 
be  expected  here. 

(2)  Open  operation  should  be  performed  after  about  two  days,  the  joint 
being  bandaged  firmly  in  the  meantime  to  check  all  bleeding  from  the  torn 
surfaces  ;  there  is  no  other  reason  for  delay.  Operative  measures  should 
always  be  open,  since  subcutaneous  wiring  cannot  possibly  overcome  the 
tilting  of  the  fragments  and  the  intervention  of  aponeurosis,  which  alone 
will  render  bony  union  certain.     A  U-shaped  flap  is  turned  down  rather 


L 


\  TEXTBOOK  OF  SURGERY 

than  up  (since  the  skin  is  better  above  than  below  the  knee),  the  base 
of  tin-  flap  being  over  the  Eronl  of  the  condyles  <»l  the  femur  and  the  flap 
long  enough  to  give  ready  access  to  both  fragments.  The  fragments  are 
exposed  freely  and  the  aponeurosis  turned  hack  from  the  fractured  ends; 
blood-clot  is  removed  from  the  joint  and  the  fragments  are  bored  for  the 
wires,  which  are  more  suitable  here  than  plates.  Various  methods  of 
introducing  the  wires  have  been  advocated  :  the  original  method  of  Lister, 
who  used  two  wire-  passed  obliquely  so  as  not  to  interfere  with  the  cartilage- 
covered  surface,  is  likely  to  result  in  the  wire  cutting  out. 

If  similar  pairs  of  bore-holes  be  made  and  the  wire  introduced  as  a 

mattress  suture,  the  fragments  tend  to  tilt.     On  the  whole  the  plan  advo- 

i  by  Hey  Groves  seems  best:    two  wires  are  used,  each  being  passed 

transversely  through  one  fragment,  well  away  from  the  cartilaginous  surface  ; 

the  ends  on  either  side  are  then  twisted  together. 

We  have  found  this    plan   very  useful,  and   it   is 

especially  advantageous  when  the  lower  fragment 

>      is  too  small  to  hold  the  wire,  as  usually  introduced, 

?XX**\-^-^~~~^J h°*\     since   it   then   can   be   passed  chiefly  through  the 

^y; ,"»Z/  strong  patellar  ligament.    After  securing  good  appo- 

/  sition  of  the  fragments  by  twisting  up  the  wires 

the  aponeurosis  will  be  carefully  sutured  over  these, 
as  well  as  the  capsule  of  the  joint  at  the  sides  of 

Pig.   135.     Wiring    the  the  patella,  and  the  skin  sutured  as  usual. 
patella  with  two  trans-  The   n     b  d        ,      be   restramed   on  a  gpj^t 

versely     placed     wires.  J  * 

(Hey  Groves'e  method.)  till  the  patient  is  round  from  the  anaesthetic.     The 

muscles  of  the  thigh  are  massaged  from  the  first ; 
passive  movements  of  the  knee  are  commenced  about  the  fifth  day,  very 
gently  at  first,  and  in  favourable  cases  the  knee  should  flex  to  a  right  angle 
inside  three  weeks.  After  the  stitches  are  removed  the  joint  is  massaged 
daily,  and  special  care  is  taken  to  move  the  patella  about  in  order  to  prevent 
its  becoming  adherent  to  the  front  of  the  femur.  The  patient  should  have 
a  Btrong,  useful  limb  in  from  six  to  eight  weeks. 

Old  Fractures  of  the  Patella.  Patients  may  apply  for  relief  of  this  con- 
dition, finding  that  the  fibrous  union  is  not  strong  enough  to  give  satisfactory 
use  of  the  limb.  These  cases  present  some  difficulty  at  operation,  since  not 
only  are  the  fragments  widely  separated  but  the  quadriceps  is  shortened  to 
adapt  itself  to  the  increased  length  of  its  patella-insertion,  and  very  likely 
the  fragments  cannot  be  approximated,  while  the  upper  fragment  is  often 
adherent  to  the  femur.  The  fragments  must  be  freed  from  adhesions  and 
maybe  brought  into  apposition ;  further,  the  quadriceps  maybe  lengthened  by 
interdigitating  incisions  on  either  side  as  in  tendon-lengthening,  or,  if  this 
be  insufficient,  a  two-stage  operation  may  be  planned.  The  fragments  are 
broughl  as  close  as  possible  with  the  leg  extended  and  the  thigh  well  flexed, 
and  retained  with  a  wire  in  such  position  (by  this  means  the  fragments 
will  probably  be  brought  within  an  inch  of  each  other).  Then  the  thigh  is 
gradually  broughl  down  and  the  tense  rectus  stretched  by  passive  move- 


DISLOCATIONS  OF  THE  PATELLA  329 

ments  for  some  weeks  ;  after  which  the  part  is  explored  again,  and  it  will 
be  found  that  the  fragments  can  be  brought  into  apposition  and  wired  closely 
so  as  to  obtain  bony  union  ;  after  which  more  passive  movements  will  be 
needed  to  stretch  the  rectus  femoris. 

(4)  Dislocations  and  Derangements  of  the  Knee-joint.  The  fol- 
lowing lesions  are  met  with  :  Dislocation  of  the  tibia  from  the  femur  (dis- 
location of  the  knee) ;  dislocation  of  the  patella  ;  sprains  and  ruptures  of 
ligaments  ;  rupture  of  the  rectus  femoris  ;  derangements  and  separations 
of  the  semilunar  cartilages  and  synovial  fringes. 

(a)  Dislocations  of  the  knee-joint  are  extremely  rare  and  are  usually  in 
a  lateral  direction  and  incomplete  ;  the  rarer  anterior  and  posterior  disloca- 
tions are  usually  complete  :   these  injuries  are  the  result  of  great  violence. 

Signs.  In  the  anterior  and  posterior  varieties  there  is  great  deformity 
of  the  limb  with  shortening.  When  the  tibia  is  displaced  forward  (the 
more  usual  form)  its  upper  extremity  with  the  patella  can  readily  be  made  out 
in  front,  there  is  a  hollow  above  this.  When  the  tibia  is  displaced  backward 
the  condyles  of  the  femur  form  a  marked  projection  in  front  with  a  hollow 
below  them.  In  either  variety  there  is  considerable  risk  of  the  popliteal 
vessels  being  torn  or  otherwise  damaged  by  the  bone  which  projects  ;it 
the  back,  leading  to  gangrene  of  the  foot.  In  the  lateral  forms  the  dis- 
placement is  less,  but  the  change  in  the  relation  of  the  condyles  of  the  femur 
to  the  upper  end  of  the  tibia  can  be  distinctly  made  out. 

Treatment.  Reduction  is  readily  brought  about  by  traction  under  an 
anaesthetic  with  manipulation  of  the  head  of  the  tibia.  Firm  elastic  pressure 
over  the  joint  for  a  week  to  limit  the  effusion,  followed  by  massage,  exercises, 
and  a  knee-cap  for  several  months,  will  form  the  after-treatment. 

(b)  Dislocation  of  the  Patella.  The  patella  may  be  displaced  outward 
or  inward  or  rotated  on  its  vertical  axis. 

(1)  The  displacement  outward  is  the  only  form  at  all  common,  and  is 
particularly  likely  to  occur  in  persons  suffering  from  genu  valgum,  either 
from  direct  or  muscular  violence,  owing  to  the  altered  direction  of  the  pull 
of  the  quadriceps  in  these  patients. 

Signs.  The  patella  lies  on  the  external  condyle  or  even  on  its  outer 
side,  while  the  intercondylar  notch  is  distinctly  perceived,  being  no  longer 
covered  by  the  patella. 

Treatment.  The  rectus  femoris  is  relaxed  by  extending  the  leg  and 
flexing  the  thigh  on  the  abdomen,  when  the  patella  can  readily  be  pushed 
into  place.  Recurrent  instances  of  this  dislocation  are  associated  with, 
and  largely  due  to,  genu  valgum,  and  are  to  be  treated  by  curing  the  latter 
condition  by  an  osteotomy  of  the  femur  just  above  the  adductor  tubercle, 
together  with  excising  part  of  the  slack  capsule  on  the  inner  side  of  the 
joint  and  suturing  the  vastus  internus  into  the  patella. 

(2)  The  dislocation  inwards  is  treated  in  a  similar  way  to  the  external 
variety  ;  it  has  not  the  same  tendency  to  recur  or  become  chronic. 

(3)  The  patella  may  be  rotated  in  either  direction  on  its  vertical  axis. 
so  that  one  of  the  <><|g<-s  is  in  front,  the  other  edge  jamming  in  the  inter- 


A  TEXTBOOK  OF  SURGERY 

condylar  notch;  in  rare  instances  the  bone  may  be  completely  rotated  bo 
that  the  cartilage-covered  surface  faces  forwards. 

Treatment  is  by  manipulation  after  relaxing  the  rectus  femoris,  as  in 
the  other  varieties. 

(c)  Sprains  and  Derangements  of  the  Knee.  A  joint  which  owes  its 
strength  to  ligaments  and  which  is  situated  between  two  long  and  powerful 
levers,  the  femur  and  tibia,  and.  further,  which  has  a  rather  complicated 
internal  mechanism  of  cartilages  and  ligaments,  it  is  not  surprising  that 
the  knee  is  the  seat  of  a  great  variety  of  injuries  besides  the  more  gross  and 
far  rarer  dislocations. 

It  is  perhaps  simples!  to  divide  these  minor  lesions  into  : 

(1)  External,  including  ruptures  of  ligaments,  tendons,  and  muscles. 

(2)  Internal,  of  which  injuries  to  the  semilunar  cartilages  are  the  most 
important,  but  including  injuries  to  the  crucial  ligaments,  synovial  fringes, 
&c. 

(1)  External  Derangements  of  the  Knee-joint.  We  include  here 
rupture  of  the  rectus  femoris,  of  the  ligamentum  patellae,  and  of  the  lateral 
ligaments. 

(a)  Rupture  of  the  rectus  femoris  is  due  to  a  sudden  violent  effort  to 
extend  the  leg.  similar  to  that  causing  fracture  of  the  patella,  to  which  this 
is  an  alternative  and  much  rarer  lesion.  The  injury  is  characterized  by 
inability  to  extend  the  leg  fully,  while  a  distinct  gap  can  be  felt  and  some- 
times seen  in  the  rectus,  above  which  the  soft  fleshy  belly  of  the  muscle 
can  be  made  out. 

Treatment.  Unless  contra-indicated  by  the  bad  condition  of  the  patient, 
the  best  method  is  to  explore  the  point  of  rupture  and  unite  the  muscle 
by  strong  mattress  sutures  of  chromic  catgut  or  silk — followed  in  ten  days 
by  massage  and  passive  movements  of  the  part :  active  movements  are 
commenced  very  mildly  after  three  weeks. 

(6)  Rupture  of  the  patellar  ligament  or  tendon  of  the  quadriceps  muscle 
is  caused  by  similar  muscular  violence  to  that  which  produces  fracture 
of  the  patella  or  rupture  of  the  rectus  femoris. 

Signs.  Here  again  there  is  inability  to  extend  the  leg,  efforts  to  do 
this  b''iiiLr  associated  with  a  riding  of  the  patella  up  the  front  of  the  thigh, 
from  the  traction  of  the  quadriceps. 

tment.  The  ligament  must  be  exposed  by  incision  and  securely 
sutured  with  chromic  gut  or  silk  of  adequate  strength  to  resist  the  powerful 
movements  of  the  quadriceps.  After-treatment  is  as  for  rupture  of  the 
rectus  femoris,  but  care  must  be  taken  that  active  movements  are  very 
mild  for  three  months  to  avoid  overstretching  or  again  rupturing  the  recently 
united  tendon  :  consequently  such  movements  as  going  upstairs  should 
be  avoided  with  the  injured  limb  for  a  considerable  time. 

(r)  Rupture  of  the  lateral  ligaments  is  due  to  violent  lateral  movements 
of  the  leg  on  the  thigh. 

The  internal  lateral  ligament  is  the  one  more  commonly  affected,  the 
signs  being  effusion  into  the  joint  with  lateral  mobility  of  the  extended 


INTERNAL  DERANGEMENTS  OF  THE  KNEE  331 

leg — in  the  direction  of  abduction  if  the  internal  ligament  be  ruptured,  and 
in  the  opposite  direction  with  lesions  of  the  external  lateral  ligament. 

Treatment.  In  most  instances  the  rupture  is  partial,  and  it  will  suffice 
to  keep  the  linib  on  a  back  splint  with  elastic  pressure  for  the  first  week 
by  bandaging  over  wool,  followed  by  massage.  Should  the  rupture  be 
complete  the  best  plan  will  be  to  suture  by  open  operation. 

After  the  splint  is  discarded  and  the  patient  begins  to  get  about,  a 
leather  knee-cap  with  hinged  steel  supports  at  the  sides  should  be  worn  for 
six  months  to  prevent  lateral  displacement,  and  use  made  of  active  move- 
ments of  pure  extension  and  flexion,  such  as  cycling. 

(2)  Internal  Derangements  of  the  Knee.     In  this  group  are  found  : 

(a)  Injuries  and  displacements  of  the  semilunar  cartilages. 

(6)  Rupture  of  the  crucial  ligaments. 

(c)  Injuries  of  the  synovial  fringes. 

(d)  Loose  bodies  inside  the  joint. 

(a)  The  internal  semilunar  cartilage  is  far  more  often  affected  than 
the  outer,  in  the  proportion  of  nine  to  one,  and  there  are  several  things  which 
may  happen  to  it  :  (1)  it  may  be  torn  from  its  anterior  attachment ; 
(2)  split  longitudinally ;  (3)  loosened  from  its  attachment  by  the  coronary 
ligaments  to  the  tibia,  the  latter  being  torn  or  stretched  so  that  the  cartilage 
luxates  inwards ;  (4)  it  may  be  broken  across  transversely ;  (5)  folded 
transversely  or  longitudinally  ;  (6)  or  there  may  be  a  nodular  enlargement 
from  bruising  of  the  anterior  part. 

Causes.  A  single  act  of  violence  will  tear  the  cartilage  from  its  attach- 
ment or  rupture  it  in  any  direction,  while  repeated  but  slight  injuries  may 
stretch  its  attachments  and  so  cause  luxation  or  lead  to  nodular  thickening 
where  bruising  has  taken  place.  The  mechanism  producing  the  lesion  has 
given  rise  to  much  discussion  ;  it  seems  to  be  nearly  always  associated  with 
rotation  of  the  tibia  on  the  femur,  but  whether  in  semiflexion,  as  is  com- 
monly held,  or  by  hyperextension,  as  maintained  by  Walton,  is  undecided. 
The  latter  observer  makes  out  a  very  good  case  for  the  well-known  screw- 
home  movement  of  the  tibia  on  the  femur  in  the  later  stages  of  forcible 
extension  as  being  responsible,  the  cartilage  being  crushed  between  the 
bones.  But  the  commonness  of  the  lesion  in  miners,  who  are  constantly  in 
a  stooping  posture,  renders  it  probable  that  the  accident  can  occur  readily 
in  the  flexed  position  of  the  knee. 

Signs.  After  a  severe  wrench,  twist,  or  sudden  hyperextension  of  the 
joint,  as  in  missing  a  kick,  the  patient  has  intense  sickening  pain  in  the 
joint,  which  remains  locked  in  a  position  of  semiflexion,  and  marked  tender- 
ness over  the  inner  border  of  the  cartilage.  This  locking  may  be  obviated 
by  the  patient  or  may  persist  several  days  unless  the  surgeon  interferes  ; 
effusion  into  the  joint  is  usual.  Complete  extension  is  usually  not  possible, 
while  flexion  is  often  painless.  Very  occasionally  the  cartilage  is  displaced 
outwards  and  forms  a  perceptible  protrusion  under  the  skin. 

The  condition,  after  the  effusion  subsides,  may  not  cause  further  trouble 
but  is  extremely  liable  to  relapse  on  slight  movements,  while  the  painful 


\  TEXTBOOK  OF  SURGERY 

locking  of  the  joint,  with  effusion,  seriously  interferes  with  the  patient's 
powers  of  locomotion,  and  later  may  lead  to  osteo-arthritic  changes  in  the 
joint. 

Diagnosis  from  injuries  to  the  synovial  fringes  and  locking  by  loose 
bodies  in  the  joint  is  not  easy,  mainly  turning  on  the  history.  Locking 
at  the  onset  of  the  first  attack  points  to  injury  of  the  semilunar  cartilage. 
Bui  it  is  often  impossible  to  1"'  certain  of  the  nature  of  the  lesion  before 
the  joint  is  opened  (si  -  p.  398). 

Treatment.  The  lirst  step  in  a  recent  case  is  to  reduce  the  displaced 
cartilage.  This  is  done  by  flexing  the  leg  on  the  thigh  and  the  thigh  on 
the  abdomen  to  relax  the  muscles  and  ligaments.  The  leg  is  then  abducted 
on  the  thigh  to  increase  the  space  between  the  internal  condyle  and  the  head 
of  the  tibia,  and  tin1  lei:  rotated  on  its  axis  in  either  direction.  The  cartilage 
generally  becomes  reduced  with  an  audible  snap  at  some  stage  of  these 
evolutions,  and  the  leg  can  then  lie  fully  extended  on  the  thigh.  The 
after-treatment  is  like  that  for  other  sprains,  by  elastic  pressure  to  the  joint, 
using  a  domette  bandage  firmly  applied  over  wool  for  a  week,  followed  by 
active  movements  and  massage-  the  movements  being  purely  flexion  and 
extension,  rotation  being  avoided.  The  patient  walks  in  about  fourteen 
days,  wearing  a  bandage  to  restrain  the  movements  of  the  joint;  active 
movements,  such  as  rowing  on  a  sliding  seat  or  cycling,  should  be  kept  up 
for  several  months,  till  the  joint  has  recovered  its  strength.  In  this  way 
a  certain  number  of  cases  will  remain  cured,  but  in  spite  of  all  care  to  avoid 
rotation,  relapses  will  take  place,  with  locking  and  effusion  into  the  joint ; 
when  this  happens  there  are  two  courses  open,  palliative  and  operative. 

Palliative  treatment  consists  in  wearing  an  apparatus  which  allows 
flexion  and  extension  but  prevents  rotation  and  lateral  movements.  Such 
instruments  are  expensive  and  clumsy,  and  prevent  the  patient  taking  part 
in  active  occupations;  they  are  only  admissible  where  there  are  strong 
reasons  against  operation. 

Operative  measures  usually  result  in  complete  cure,  and  consist  in 
opening  the  joint  and  removing  the  offending  cartilage,  or  at  least  the 
damaged  part  thereof.  This  may  be  done  by  an  incision  on  the  inner  and 
anterioT  aspect  of  the  joint,  which  is  semiflexed;  the  incision  is  vertical  and 
just  in  front  ot  the  internal  lateral  ligament,  its  middle  opposite  the  line 
of  the  joint  (Mai tin  advises  a  horizontal  skin  incision  over  the  line  of  the 
joint). 

The  capsule  is  opened  between  the  patellar  ligament  and  the  internal 
lateral  ligamenl  and  the  interior  of  the  joint  explored;  the  anterior  part 
of  the  cartilage  is  removed  if  damaged  in  any  of  the  above-mentioned  ways, 
and  the  crucial  ligaments  and  external  cartilage  and  the  fringes  inspected. 

'I  he  all-important  feature  in  this  operation  is  asepsis,  and  it  should  only 
lie  performed  by  those  in  constant  practice  with  major  surgery,  since  opening 
the  knee-joint  is  considerably  more  risky  than  opening  the  peritoneum, 
and  no  pains  should  be  spared  to  prevent  such  a  catastrophe  as  the  infection 
of  this  importanl  joint.     After  operation  massage  can  be  started  during  the 


RUPTURE  OF  THE  CRUCIAL  LIGAMENTS  333 

first  week,  active  movements  in  ten  days,  of  the  variety  described  under 
the  general  treatment  of  this  lesion. 

Displacement  of  the  external  semilunar  cartilage  is  much  less  common 
than  of  the  internal ;  the  causes  and  signs  are  similar  except  that  the  point 
of  greatest  tenderness  is  over  the  outer  side  of  the  joint.  Treatment  is  on 
the  same  lines  as  that  for  injury  to  the  internal  cartilage. 

(b)  Rupture  of  the  Crucial  Ligaments.  This  is  caused  by  severe  injuries, 
and  will  cause  abnormal  lateral  and  rotary  as  well  as  antero-posterior  mobi- 
lity of  the  joint  while  in  extension.  If  the  anterior  ligament  alone  be 
ruptured  there  will  be  an  abnormal  displacement  of  the  extended  tibia 
forward  on  the  femur,  while  if  the  posterior  crucial  be  torn  there  will  be 
abnormal  displacement  of  the  flexed  tibia  backward  on  the  femur. 

Such  cases  are  likely  to  be  regarded  as  bad  sprains,  but  when  the  abnormal 
mobility  persists  the  joint  should  be  explored  and  the  ligaments  sutured 
with  chromic  gut.  Avulsion  of  the  spine  of  the  tibia  has  been  already 
described,  and  is  an  alternative  or  associated  lesion  with  rupture  of  the 
crucial  ligaments. 

(c)  As  a  result  of  recurrent  synovitis  the  synovial  fringes  of  the  liga- 
mentum  mucosum  and  ligamenta  alaria  may  hypertrophy,  becoming 
enlarged,  tough  and  fibrous,  and  may  develop  nodules  of  cartilage  in  their 
substance  which  may  grow  to  a  considerable  size.  Similar  changes  may  be 
initiated  from  nipping  of  the  fringes  between  the  bones  in  movements  of  the 
joint.  Such  nipping  of  the  nodules  of  cartilage  may  cause  locking  of  the 
joint,  or  the  larger  masses  may  become  detached  and  form  loose  floating 
bodies  in  the  joint ;  finally  these  bodies  may  become  completely  loose  and 
travel  about  the  joint  cavity  as  "  joint  mice  "  (other  conditions  leading  to 
the  formation  of  such  "  joint  mice  "  are  (a)  detachment  of  part  of  a  semi- 
lunar cartilage  or  (b)  part  of  the  articular  cartilage,  or  (c)  organization  of 
blood-clot,  in  any  case  the  lesion  being  due  originally  to  some  injury). 

Diagnosis.  The  exact  diagnosis  of  these  cases  is  in  many  instances  far 
from  easy,  as  two  of  the  main  signs  of  a  displaced  semilunar  cartilage  are 
present,  viz.  locking  and  effusion,  but  the  tenderness  is  not  referred  to  the 
position  of  one  of  the  cartilages,  while  a  loose  body,  if  of  any  size,  can 
generally  be  felt  at  some  time  or  other  in  a  position  well  away  from  the 
upper  end  of  the  tibia. 

Treatment  is  as  for  chronic  synovitis  arising  from  sprains,  viz.  elastic 
pressure  with  bandage  or  strapping,  hot  and  cold  douches,  active  movements 
of  extension  and  flexion,  with  massage. 

When  this  line  of  treatment  fails  after  some  weeks,  or  if  the  affection 
recurs,  pointing  to  hypertrophic  fringes,  or  if  a  loose  body  can  be  definitely 
made  out  by  palpation,  the  joint  should  be  explored  under  conditions  of 
extreme  asepsis,  and  the  redundant  fringes  or  the  loose  body  removed,  lest 
the  joint  pass  into  a  condition  of  osteo-arthritis. 


\  TEXTBOOK  OF  si  i;<;i:i;y 

(e)  INJURIES  OF   THE  LEG 

Anatomy.  The  shaft  of  the  tibia  is  subcutaneous  and  can  readily  be 
palpated  throughout  its  Length  ;  this  closeness  to  the  skin  renders  this 
the  most  common  situation  for  compound  fractures.  The  shaft  of  the  fibula 
!-  entirely  covered  by  muscles  in  the  upper  two-thirds,  in  the  lower  pari  is 
subcutaneous  and  readily  traced  to  the  subcutaneous  external  malleolus. 

The  following  injuries  are  described  :  (1)  Fractures  of  the  tibia  and  fibula 
(-haft)  ;   (2)  rupture  of  muscles  and  tendons. 

(1)  Fractures  of  the  Tibia  and  Fibula.  These  bones  may  be 
fractured  separately  or  together,  the  latter  being  considerably  more 
usual. 

(a)  Fracture  of  the  tibia  alone  may  be  due  to  direct  violence,  when  the 
bone  gives  way  in  any  position,  or  indirect,  when  the  common  site  of  fracture 
is  the  junction  of  the  middle  and  lower  thirds.  This  type  of  fracture  is 
more  usual  in  children,  being  then  often  subperiosteal. 

Signs.  There  is  usually  but  little  displacement,  in  some  instances  none 
at  all.  the  fibula  acting  as  a  splint  and  preventing  displacement. 

Great  tenderness  and  swelling  at  some  point  of  the  bone  and  abnormal 
mobility  may  be  noted,  but  the  latter  sign  is  often  missing  in  cases  of  sub- 
periosteal fracture.  Irregularity  of  the  surface  can  be  easily  felt  when 
present,  the  upper  fragment  projecting  in  front  of  the  lower. 

Treatment.  Where  there  is  displacement  this  should  be  reduced  by 
traction  and  manipulation  under  ana?sthesia  if  necessary,  and  the  leg  placed 
on  a  well-padded  back-splint  with  foot-piece  at  right  angles  (Fig.  136).  A 
heel-pad  should  be  inserted  under  the  tendo  Achillis  just  above  the  projection 
of  the  os  calcis  to  avoid  pressure  on  the  latter.  (A  heel-sore  is  one  of  the 
worst  complications  of  fractures  of  the  leg.)  The  leg  should  be  bandaged  to 
the  back-splint,  care  being  taken  that  the  foot  is  at  right  angles,  and 
then  well-padded  side-splints  fastened  with  webbing  straps.  The  leg  thus 
equipped  is  slung  in  a  cradle,  of  which  Bloxam's  is  a  good  type.  In  fourteen 
days  or  earlier  there  will  be  enough  union  to  allow  of  the  application  of  a 
divided  plaster,  the  patient  going  on  crutches,  while  the  leg  is  massaged 
and  passive  movements  of  the  ankle  and  knee  are  practised.  The  weight 
ran  be  taken  on  the  limb  in  four  to  eight  weeks,  according  to  the  age  of 
the  patient. 

Plasters  for  the  leg  can  be  applied  in  one  of  two  methods  : 

(J)  Croft's  method  consists  in  cutting  out  four  L-shaped  pieces  of  Bava- 
rian flannel,  two  for  each  side.  These  are  wetted  and  impregnated  with  a 
recently  made  cream  of  plaster  of  Paris,  each  pair  being  placed  between  f  wo 
pieces  of  lint  of  the  same  shape  but  slightly  larger  size.  These  sandwiches 
of  lint  and  plastered  flannel  are  rapidly  bandaged  On  each  side  of  the  leg 
in  turn.  Speed  is  needed  to  have  each  sandwich  applied  before  the  plaster 
and  care  to  keep  the  foot  at  right  angles.  When  the  plaster  is 
firmly  set,  as  happens  in  a  few  minutes,  the  bandages  are  removed  and 
there  will  be  left  accurately  fitting  internal  and  external  plaster-cases  ;  these 


FRACTURES  OF  THE  TIBIA  AND  FIBULA 


335 


are  trimmed  and  finished  off  with  a  binding  of  strapping,  and,  if  properly 
made,  should  last  two  or  three  months  without  softening. 

(2)  The  limb  is  covered  with  a  flannel  bandage  and  over  this  a  sufficiency 
of  ordinary  plaster  bandages  applied  to  produce  a  firm  case.  When  this 
has  set,  but  before  it  dries,  it  may  readily  be  cut  down  fore  and  aft  with 
a  sharp  knife,  again  giving  an  internal  and  external  case  of  plaster. 

Whichever  plan  be  used,  the  plaster  must  be  dried  in  a  warm  place 
(not  in  front  of  the  fire  or  it  will  crumble)  for  twenty-four  hours. 

Where  there  is  no  separation  and  but  slight  effusion,  such  plasters  may 
be  applied  after  resting  the  limb  between  sand-bags  for  twenty-four  hours 
to  see  that  there  will  not  be  much  effusion,  and  the  limb  massaged  from  the 
third  day.    But  this  method  should  only  be  used  if  the  patient  is  under 


Fig.  136.     The  employment  of  back  and  side  splints  for  fractures  of  the  leg,  the 

whole  being  slung  in  a  Bloxam's  cradle,  which  causes  flexion  of   the  knee,  thus 

relaxincr  the  tension  of  the  aiastroeneniius. 


supervision  for  the  first  few  days,  or  effusion  may  cause  great  pressure  inside 
the  dense  plaster-case  and  produce  ischaemic  contracture  or  sloughing. 

(b)  The  fractures  of  the  shaft  of  the  fibula  alone  are  due  to  direct  violence, 
except  that  the  lower  end  may  break  as  the  result  of  severe  eversion  of  the 
foot  at  the  ankle  :  this  last  condition  is  considered  with  fracture-dislocations 
of  the  ankle  (Pott's  fracture). 

Signs.  There  is  little  disability,  the  patient  being  able  to  walk.  Swell- 
ing and  tenderness  over  the  seat  of  fracture  are  noted,  but  crepitus  is  seldom 
obtained.  A  special  sign,  however,  is  present :  when  the  normal  leg  is 
firmly  grasped  the  fibula  can  be  bent  in  towards  the  tibia  to  some  extent 
and  springs  out  again,  from  its  elasticity,  when  the  pressure  is  relaxed ; 
this  is  known  as  the  "  spring  "  of  the  fibula  and  is  not  present  if  the  bone 
is  fractured. 

Treatment.  Two  or  three  days'  rest  in  bed  and  then  the  limb  can  be 
placed  in  a  divided  plaster-case,  with  massage  from  the  third  day ;    the 


A  TKVI  BOOK  OF  SI  RGERY 

plaster  can  be  omitted  in  fourteen  days,  and  the  patient  should  be  walking 
in  three  weeks. 

Fractun  of  the  Tibia  and  Fibula  together.  This  lesion  is  due  generally 
to  indirecl  violence,  and  the  line  of  fracture  is  then  oblique  the  tibia  giving 
way  in  the  lower  third,  the  fibula  higher  up.  'I  he  obliquity  of  the  fracture- 
line  in  the  tibia  is  from  above  down  and  forwards,  so  thai  the  upper  lies 
in  front  of  the  lower  fragment,  the  latter  being  pulled  up  by  the  powerful 
muscles  ^\  the  calf  and  often  slightly  rotated  out  by  the  weight  of  the  foot. 

Direcl  violence  will  cause  a  transverse  fracture  of  the  hones  in  any 
position.  Owing  to  the  proximity  of  the  skin,  the  sharp  upper  fragment  in 
oblique  fractures  is  in  great  danger  of  penetrating  the  integuments,  and 
this  is  the  commonest  site  for  compound  fractures  to  arise. 

Diagnosis.  Deformity  is  often  marked,  and  the  site  of  fracture  can 
be  easily  made  out  by  palpation  of  the  subcutaneous  surface  of  the  tibia. 
Crepitus  and  abnormal  mobility  will  be  noted,  and  effusion  and  swelling 
are  often  great.     The  normal  relation  of  the  malleoli  to  the  foot  will  exclude 


Fig.   137.     Mclntyre's  splint,  allowing  variable  flexion  of  the  knee.     Sometimes 
of  use  in  fractures  of  the  tibia  and  fibula  where  the  fragments  tend  to  override. 

Pott's  fracture.     Less  commonly  the  fractures  may  be  subperiosteal  and 
show  no  deformity  and  very  slight  abnormal  mobility. 

ZY< '////"  nt.  'I  his  consists  in  reduction  of  the  fragments  by  traction,  as  in 
fractures  of  the  tibia  alone  (attention  is  paid  only  to  the  tibia  ;  if  this  is  in 
position  the  fibula  follows  suit),  and  placing  it  on  a  back-splint  with  a  foot- 
piece  as  in  the  fonner  fracture.  While  on  the  splint  there  is  considerable 
tendency  for  oblique  fractures  to  become  again  displaced,  and  radiographs 
should  he  taken  during  the  first  few  days,  and  if  deformity  recurs  the  fracture 
should  he  exposed  by  open  operation  and  plated  in  position.  If,  however, 
the  position  remains  good  the  splints  may  be  left  on  fourteen  days  and 
then  removed  for  inspection;  if  there  is  little  swelling  and  some  attempt 
at  union,  a  divided  plaster  may  be  applied.  More  usually  the  fracture  will 
still  he  too  little  secure  for  tin.-;,  and  the  splint  will  need  to  be  re-applied 
for  another  week  or  two,  after  which  the  divided  plaster  is  applied  and  the 
patient  goes  aboul  with  the  aid  of  crutches.  As  the  limb  becomes  firm 
weight  can  l>e  gradually  borne  upon  it,  at  first  with  the  plaster  on;  later 
boul  six  to  eighl  weeks)  this  is  removed.  While  in  the  plaster  the  limb 
should  he  massaged  daily  and  passive  movements  of  the  ankle  and  knee 
practised  to  prevent  these  important  joints  from  becoming  stiff  and  to 
crease  the  rapidity  of  union.     Thus  it  will  be  seen  that  the  sooner  the 


FRACTURES  OF  THE  TIBIA 


337 


limb  can  be  got  into  the  divided  plaster  the  more  rapidly  it  will  be  restored 
to  its  normal  functions.  Delayed  union  is  fairly  common  in  these  fractures, 
but  seldom  if  early  massage  be  efficiently  carried  out.  Where  union  is 
delayed  and  the  position  of  the  fragments  is  good,  very  vigorous  massage 
(strong  petrissage,  hacking,  clapping,  &c.)  should  be  carried  out. 

In  oblique  fractures  at  this  situation  it  will  fairly  often  be  impossible 
to  prevent  the  recurrence  of  deformity  by  splints  alone,  and  in  cases  where 
the  error  of  alignment  is  more  than  one- 
quarter  of  an  inch  in  adults  or  one  half-inch 
in  children,  or  where  apposition  is  prevented 
by  interposition  of  muscle,  it  will  be  best 
to  fix  the  fragments  in  good  position  by 
the  use  of  open  operation  and  a  plate.  The 
same  treatment  will  be  employed  in  cases  of 
delayed  union  which  persist  after  a  course 
of  vigorous  massage  for  two  months. 

Compound  fractures  are  relatively  com- 
mon in  this  situation,  and  must  be  attended 
to  at  once  and  rendered  aseptic  ;  delays  are 
dangerous  and  likely  to  result  in  severe  in- 
fection. Should  the  fragments  not  readily 
remain  in  apposition  after  the  wound  has 
been  rendered  as  aseptic  as  possible,  they 
should  be  fixed  with  plate  or  wire  ;  for 
even  if  suppuration  takes  place  the  plates 
can  as  a  rule  be  retained  long  enough  to 
keep  the  fragments  in  position,  and  if  they 
have  to  be  removed  after  a  month  or  six 
weeks  the  ultimate  position  will  be  much 
better  than  if  the  fragments  were  allowed 
to  go  their  own  way. 

(2)  Rupture  of  Muscle-fibres  in  the 
Calf.  This  accident  occurs  so  frequently 
while  playing  tennis  as  to  have  acquired  the 
name  of  "  tennis  leg."  The  condition  is  prob- 
ably due  to  rupture  of  fibres  of  the  gastroc- 
nemius or  soleus.  The  plantaris,  which  has  been  taken  to  task  for  this 
lesion,  seems  unlikely  to  be  at  fault,  for  with  so  long,  thin,  and  elastic  a 
tendon  it  is  hard  to  believe  that  its  short  weak  belly  could  cause  rupture. 
The  accident  occurs  in  some  sharp,  sudden,  and  violent  extension  of  the 
foot  and  the  patient  experiences  severe  pain  in  the  calf,  as  if  struck  with 
a  stick  ;   he  walks  with  a  limp  and  swelling  of  the  calf  appears. 

Treatment.  The  leg  is  strapped  firmly  from  ankle  to  knee  and  the 
patient  encouraged  to  walk,  bringing  the  heel  to  the  ground  at  every  step. 
The  pain  will  become  much  less  in  a  few  minutes  with  perseverance  in 
walking.     The  strapping  is  changed  as  often  as  it  becomes  loose  from 


Fig.    138.      Comminuted  fracture 

of  the  tibia  secured  by  encircling 

wires. 


22 


\  TEXTBOOK  OF  SUEGERY 

absorption  of  the  effused  blood.     Aft cv  the  effusion  is  absorbed  massage  for 
a  few  davs  will  complete  the  cure. 

(/)  INJURIES  ABOUT   THE   ANKLE-JOINT 

Many  varieties  of  lesion  occur  in  this  situation,  of  which  the  following 
are  described:  (1)  Sprains ;  (2)  fractures  and  fracture-dislocations  of 
the  lower  ends  of  the  tibia  and  fibula;  (3)  dislocations  of  the  ankle; 
(4)  fractures  of  the  tarsal  bones. 

Anatomy.  The  ankle  is  a  hinge  joint— the  astragalus,  bearing  the  foot, 
being  mortised  in  between  the  malleoli,  of  which  the  external  is  the  larger, 
extending  $  in.  lower  and  ^  in.  further  back  than  the  internal  malleolus. 
The  sustentaculum  tali  of  the  os  calcis  is  £  in.  below  the  tip  of  the  internal 
malleolus:  If  in.  in  front  of  the  latter  is  the  tubercle  of  scaphoid.  The 
lower  end  of  the  tibia  is  subcutaneous  through  its  extent  and  the  lower 
end  of  the  fibula  also  for  the  last  4  in.,  above  which  it  is  gradually  covered 
by  the  peronei  and  tibial  muscles.  The  line  of  the  ankle-joint  is  -|-  in. 
above  the  tip  of  the  internal  malleolus.  The  head  of  the  astragalus  can 
be  felt  on  the  dorsum  of  the  foot  an  inch  in  front  of  the  anterior  surface 
of  the  tibia. 

(1)  Sprains  of  the  Ankle-joint.  These  are  of  common  occurrence 
and  are  usually  caused  by  a  wrench  of  the  foot  outward,  a  minor  degree 
of  the  violence  which  causes  fractures  and  fracture-dislocations  in  this 
region. 

The  ligaments  of  most  consequence  in  this  injury  are  the  internal -lateral 
of  the  ankle,  which  fixes  the  internal  malleolus  to  the  sustentaculum  tali, 
astragalus,  and  scaphoid  ;  the  calcaneo-scaphoid,  which  supports  the  head 
of  the  astragalus,  and  the  insertions  of  the  tibialis  posticus  into  the  scaphoid 
and  other  tarsals,  bracing  up  the  arch  of  the  foot.  If  these  ligaments  are 
badly  torn  there  is  considerable  prospect  of  the  foot  becoming  displaced 
outward  and  losing  its  arch,  falling  into  the  position  of  splay  or  fiat-foot. 

Diagnosis.  Swelling  and  ecchymosis,  with  pain  on  moving  the  joint,  wall 
be  found.  The  effusion  is  behind,  on  either  side  of  the  tendo  Achillis,  and 
to  a  less  degree  in  front.  There  will  be  no  crepitus,  abnormal  mobility 
or  swelling  of  the  lower  ends  of  the  tibia  and  fibula. 

Treatment.  Elastic  pressure  to  reduce  the  effusion  is  best  maintained 
by  strapping  applied  in  encircling  lengths  from  the  ball  of  the  foot  to  3  in. 
above  the  ankle.  Active  movements  of  flexion  and  extension  are  encouraged 
from  the  start,  but  the  foot  is  not  placed  on  the  ground  for  ten  days  or 
more,  and  before  the  patient  is  allowTed  to  wralk  the  ankle  should  be  examined, 
and  if  there  is  any  tendency  for  the  internal-lateral  ligament  to  stretch, 
the  inner  side  of  the  sole  of  the  boot  should  be  thickened  J  in.  as  in  the 
treatment  of  flat-foot,  to  shift  the  weight  on  to  the  outer  side  of  the  foot 
and  prevent  the  structures  on  its  inner  side  being  overstretched.  Severe 
sprains  should  ahvays  be  X-rayed  to  detect  any  tearing  off  of  the  internal 
malleolus  or  fracture  of  the  fibula,  and  when  in  doubt  these  cases  should  be 
regarded  as  serious  and  treated  on  the  lines  laid  down  for  Pott's  fracture, 


POTT'S  FRACTURE  AND  ITS  CONGENERS  339 

since  a  severe  sprain  may  be  just  as  serious  in  its  consequences  as  the  last 
condition. 

(2)  Fractures  and  Fracture-dislocations  of  the  Lower  Tibia  and 
Fibula.  Mechanism.  When  the  foot  is  forcibly  wrenched  outward,  as  in 
slipping  off  the  kerb,  the  internal-lateral  ligament  is  strained  while  the 
astragalus  impinges  against  the  lower  end  of  the  external  malleolus  and 
forces  this  outward.  If  the  force  is  sufficiently  great  something  gives  way. 
Thus  the  ligament  may  be  ruptured,  or  the  internal  malleolus  pulled  off. 
In  other  instances  the  pushing  out  of  the  external  malleolus  bends  the 
fibula  inwards  above  the  strong  tibio-fibular  ligaments  (which  act  as  a 
fulcrum)  and  the  fibula  breaks  about  3  in.  above  its  lower  end.  Such  a 
fracture  of  the  fibula  may  occur  alone,  or  in  combination  with  a  fracture 
of  the  internal  malleolus,  or  rupture  of  the  internal-lateral  ligament,  In  the 
latter  case  there  is  a  partial  dislocation  of  the  ankle  outward  and  sometimes 
backward,  and  this  type  of  fracture-dislocation  is  known  as  Pott's  fracture. 
The  condition  originally  described  by  Pott  was  a  dislocation  of  the  foot 
out  and  back  at  the  ankle-joint  with  fracture  of  the  fibula  3  in.  up  and 
rupture  of  the  internal-lateral  ligament.  When  the  violence  is  still  greater 
the  inferior  tibio-fibular  ligaments  are  torn  and  the  astragalus  passes  up 
between  the  tibia  and  the  lower  fragment  of  the  fibula  (Dupuytren's  fracture). 

In  some  cases  both  malleoli  are  broken  off  below  the  tibio-fibular  liga- 
ments ;  in  others  the  foot  is  forced  inwards  and  the  internal  malleolus  forced 
off  the  tibia,  while  the  fibula  fractures  at  the  usual  situation. 

In  another  variety,  again,  the  tibia  is  broken  off  above  the  articulating 
surface  while  the  fibula  is  broken  at  the  usual  place.  A  similar  injury  occurs 
in  children,  the  lower  epiphysis  of  the  tibia  being  broken  off  and  displaced 
outwards  while  the  fibula  is  broken  3  in.  above  its  tip.  We  have  then  the 
following  fractures  : 

(a)  Fracture  of  the  fibula  alone,  the  internal-lateral  ligament  being 
intact. 

(6)  Fracture  of  the  internal  malleolus  alone. 

(c)  Fracture  of  the  fibula  with  rupture  of  the  internal-lateral  ligament.  I 

(rf)  Fracture  of  the  fibula  with  fracture  of  the  internal  malleolus.       f 

In  both  these  last  types  there  may  be  backward  as  well  as  outward  dis- 
placement, and  these  are  known  as  Pott's  fractures. 

(e)  Fracture  of  both  malleoli. 

(f)  Pott's  fracture  with  inward  displacement  of  the  foot  (inverted 
Pott's). 

(g)  Dupuytren's  fracture. 

(h)  Fracture  of  the  lower  fibula  with  displacement  of  the  lower  epiphysis 
of  the  tibia,  or  fracture  of  the  tibia  at  this  spot,  i.e.  above  the  ankle-joint. 
It  will  be  noted  that  all  these  fractures  with  the  exception  of  the  first  and 
last  group  are  into  the  ankle-joint. 

Diagnosis.  In  all  these  injuries  there  will  be  swelling  and  deformity  of 
the  ankle-joint,  greatest  where  the  damage  is  most,  i.e.  in  Dupuytren  s 
fracture  and  least  in  simple  fracture  of  the  fibula. 


340  A  TEXTBOOK  OF  SURGERY 

(a)  In  simple  fractures  of  the  lower  fibula  there  will  be  local  swelling 
and  tenderness,  slight  abnormal  mobitity  in  the  outward  direction  ;  crepitus 
is  Beldom  noted  and  often  an  X-ray  is  necessary  to  Bettle  the  question  of 

fracture. 

(b)  In  fracture  of  the  internal  malleolus  there  will  be  swelling  of  the 


Fro.   139.     A.  Fractured  fibula.     B  and  C,  Pott's  fractures  (2  types).     D,  Dupuy- 
fracture.      E,  Malleoli    fractured    through    the    ankle-joint.     F,  Separated 
epiphysis  of  tibia  and  fibula,     <;,  Fracture  of  the  tibia  and  fibula  low  down. 


ankle-joint  from  effusion  and  the  small  lower  fragment  may  be  felt  movable 
on  the  tibia,  and  sometimes  crepitus  will  be  elicited. 

(c)  and  (<1)  In  fracture-dislocations  of  the  Pott's  type,  in  addition  to 
much  swelling,  the  foot  is  markedly  displaced  outwards,  so  that  the  tip 
of  the  internal  malleolus  or  the  sharper  end  of  the  tibial  shaft  (where  the 
malleolus  is  broken  off)  projects  beneath  the  skin  and  is  likely  to  become 
compound  if  care  be  not  exercised.  The  foot  is  flexed  in  the  plantar  direc- 
tion by  the  powerful  calf  muscles,  and  in  a  small  proportion  of  cases  the  heel 


DIAGNOSIS  OF  POTT'S  FRACTURE 


341 


projects  backwards  owing  to  the  backward  displacement  of  the  astragalus, 
which  carries  the  foot  with  it.     (Fig.  141 .) 

(e)  Where  both  malleoli  are  broken  off  the  signs  are  very  similar. 

(/)  Fractures  of  the  internal  malleolus  and  fibula  with  inversion  are 
uncommon  and  show  marked  inversion  of  the  foot,  while  the  fractured  ends 
of  the  fibula  form  a  projection  on  the  outer 
side  of  the  ankle. 

(g)  In  Dupuytren's  fracture — a  rare  con- 
dition— there  is  gross  deformity,  the  ankle 
being  much  widened  and,  owing  to  the  dis- 
placement of  the  whole  foot  upwards,  the 
tip  of  the  internal  malleolus  is  abnormally 
near  the  sole  of  the  foot. 

(h)  In  fractures  of  the  lower  end  of  the 
tibia  above  the  joint,  or  separation  of  its 
lower  epiphysis  with  fracture  of  the  lower 
fibula,  there  is  outward  displacement  of  the 
foot  as  above  ;  but  the  relation  of  the  in- 
ternal malleolus  to  the  sustentaculum  tali 
and  the  tubercle  of  the  scaphoid  is  unaltered, 
while  the  line  of  fracture  in  the  shaft  of  the 
tibia  is  considerably  higher  than  in  fractures 
of  the  internal  malleolus. 

Treatment.  The  two  main  troubles  likely 
to  arise  from  these  injuries  are  flat-foot  and 
loss  of  dorsiflexion  of  the  foot  at  the  ankle, 
owing  to  the  contraction  of  the  calf-muscles 
or  backward  displacement  of  the  foot  or 
both,  and  treatment  should  aim  at  obvi- 
ating these  bad  after-results. 

(a)  Simple  fractures  of  the  fibula,  with 
no  outward  displacement,  may  be  treated 
as  sprains,  the  patient  being  allowed  to 
walk  in  two  or  three  weeks  ;  but  should 
there  be  much  effusion  into  the  joint,  point- 
ing to  injury  to  the  internal-lateral  liga- 
ment, it  is  best  to  treat  the  case  in  the  manner  advised  for  more  severe 
injuries,  lest  the  weakened  ligament  stretch  and  the  patient  develop  a  flat 
foot. 

(b)  (c)  (d)  (e)  (g)  (h)  The  various  forms  of  Pott's  fracture,  Dupuytren's 
fracture,  fracture  of  both  malleoli,  separation  of  the  lower  epiphysis  of 
the  tibia  with  fracture  of  the  lower  fibula,  are  treated  as,  follows  :  The 
displacement  is  reduced,  under  anaesthesia,  by  inversion,  and  care  should  be 
taken  not  to  miss  a  backward  displacement  of  the  foot  (the  amount  of 
projection  of  the  heel  behind  the  tibia  should  be  noted,  compared,  and  made 
to  correspond  with  the  sound  side),  for  if  this  backward  deformity  be  allowed 


Fig.  140.      Oblique  fracture  of  the 

lower  end  of  the  tibia  and  fibula 

simulating  Pott's  fracture. 


34*2 


A  TEXTBOOK  OF  SURGERY 


to  persisl  it  causes  greal  disability.  A.fter  reduction  the  leg  is  placed  on 
a  Sharpe's  splint.  This  consists  of  a  well-padded  external  angular  splint 
with  a  foot-piece.  The  leg  is  placed  on  this  with  a  good  pad  under  the 
ilcis,  distal  to  the  externa]  malleolus,  which  serves  al  the  same  time  to 
produce  inversion  of  the  foot  and  relieve  the  malleolus  from  pressure.  The 
foot  is  kept  at  a  right  angle  against  the  foot-piece  of  the  splint,  to  which  it 
is  firmly  bandaged — the  knee  being  much  flexed  to  relax  the  gastrocnemius, 
a  potent  factor  in  causing  plantar  flexion  and  backward  displacement  of 
the  foot.  The  bandage  is  pinned  to  the  posterior  edge  of  the  splint  just 
above  the  ankle,  passes  forward  under  the  latter,  thru  hack  round  the  leg 
and  a  small  posterior  splint,  and  so  round  the  main  splint.  In  this  manner 
the  tibia  is  pulled  backward  and  the  foot  forward,  correcting  any  tendency 
for  the   foot  to  dislocate  backward.     The  bandage  is  then  carried  round 


In;.   141.     Pott's  fracture,  displacement,     a,  Normal  outline  of  bones  of  the  ankle. 

b,  Showing  foot  displaced  back  bo  that  the  neck  of  the  astragalus  articulates  with 

the  lower  end  of  the  tibia. 


the  foot  to  secure  it  to  the  foot-piece  and  up  the  leg.     The  patient  lies  on 
the  Bide  of  the  fracture  with  the  thigh  and  leg  both  well  flexed.   (Fig.  142.) 

The  muscles  of  the  calf  may  be  massaged  from  the  third  day,  a  great 
advantage  of  this  splint  being  that  there  is  no  need  to  take  the  limb  off  it 
for  massage.  The  toes  should  be  moved  passively  from  the  outset,  the 
ankle  about  the  tenth  day.  and  active  movements  in  two  to  three  weeks. 
A  divided  plaster  may  be  fitted  in  from  two  to  three  weeks  according  to  the 
severity  of  the  injury,  but  no  weight  should  be  taken  on  the  foot  for  at 
six  weeks  in  slight  cases  :  in  more  severe  lesions  the  foot  should  be  off 
the  ground  about  three  months  and  the  inner  side  of  the  sole  of  the  boot 
should  be  thickened  a  quarter  of  an  inch  to  prevent  the  development  of 
flat-foot  when  walking  is  commenced.  In  still  more  severe  cases  it  will 
be  well  to  supply  the  patient  with  side-irons  and  valgus  T-strap  as  for  cases 
ipes  (such  cases  probably  demand  operative  measures). 

.nid  active  movements  are  most  important  at  this  stage, 
and  careful  instruction  in  these  will  greatly  help  in  obtaining  good  functional 
results:    the  following  exercises  are  advised: 


TREATMENT  OF  POTT'S  FRACTURE  343 

(1 )  To  practise  raising  the  body  on  the  toes  and  the  toes  from  the  ground 
alternately,  the  points  of  the  feet  being  inverted,  and  gradually  increasing 
the  number  of  movements  till  some  hundreds  are  performed  daily. 

(2)  To  practise  walking  with  the  toes  turned  acutely  inwards. 

(3)  To  walk  habitually  by  placing  one  foot  down  exactly  in  front  of 
the  other,  with  the  toes  pointing  straight  forwards  and  not  in  the  least 
everted.     With  after-treatment  and  on  these  lines,  and  taking  care  that  no 


Fig.   142.     The  application  of  a  Sharpens  splint  for  Pott's  fracture.     A,  Back  view 

showing  the  position  of  the  small  back-splint  and  heel  pad,  the  latter  causing  inver- 

tion  of  the  foot.     B.  Side  view  showing  the  method  of  bandaging  to  pull  the  leg 

backward  and  the  heel  (and  foot)  forward. 


backward  displacement  or  plantar  flexion  takes  place  on  the  splint,  good 
results  will  be  obtained  in  most  cases. 

(/)  For  inverted  Pott's  fracture  the  Sharpe's  splint  may  be  used  after 
preliminary  reduction,  which  should  not  be  carried  too  far,  since  a  moderate 
degree  of  over-inversion  of  the  foot  is  good  in  these  cases. 

Operative  treatment  is  seldom  necessary  in  these  cases,  but  may  be 
indicated  in  the  more  severe  grade  of  Pott's  fracture  or  that  of  Dupuvtren. 

It  will  generally  suffice  to  cut  down  and  place  the  fibula  in  good  position, 
but  if  the  lesion  on  the  inner  side  involves  the  internal  malleolus  and  not 
the  ligament  it  may  be  well  to  fasten  this  little  fragment  with  a  wire. 

(3)  Dislocations  about  the  Axkle.  Pure  dislocations,  i.e.  unasso- 
ciated  with  fracture,  in  this  situation  are  rare.     The  following  are  described  : 

(a)  Dislocation  of  the  foot  forwards  ] 

(6)  Dislocation  of  the  foot  backwards  -  at  the  ankle-joint. 

(c)  Upward  dislocation  of  the  foot 

(d)  Lateral  dislocations  of  the  foot  are  always  associated  with  fractures 
and  have  been  described  under  Pott's  fracture. 

(e)  Dislocation  of  the  astragalus. 


;n  \  TEXTBOOK  OF  SURGERY 

(/)  Subastragaloid  dislocation  of  the  Eoot. 

(a)  In  forward  dislocatioD  tin-  foot  is  markedly  elongated  and  the 
prominence  of  the  oa  calcis  (heel)  at  the  hack  is  lost. 

(b)  Tlir  more  common  backward  dislocation  is  characterized  by  the 
great  shortening  of  the  foot,  the  heel  projecting  abnormally  far  backward 
ami  the  tibia  articulating  with  the  neck  of  the  astragalus. 

(c)  In  the  very  rare  upward  dislocation  the  tibia  and  fibula  are  separated 
by  rupture  of  the  inferior  tibio-fibular  ligament,  the  astragalus  going  up 
bet  wren  them  as  in  Dupuytren's  fracture,  but  without  fracture  of  the  fibula. 
The  ankle  is  greatly  widened  and  the  malleoli  are  nearer  the  sole  of  the  foot. 

Treatment.  All  these  dislocations  are  reduced  by  traction  on  the  foot 
with  the  knee  ilexed,  to  relax  the  tendo  Achillis.  Should  the  foot  tend  to 
re-dislocate,  the  condition  should  be  treated  as  a  case  of  Pott's  fracture, 
otherwise  massage  and  movements  may  be  used  from  the  outset  without 
a  splint,  but  no  weight  taken  on  the  foot  for  at  least  a  month,  to  prevent 
any  tendency  to  the  development  of  flat-foot. 

(d)  Dislocation  of  the  astragalus  from  its  socket  occurs  forwards,  back- 
wards or  sideways,  and  may  be  complete  or  incomplete.  The  forward 
dislocation  is  the  least  uncommon,  the  bone  then  resting  on  the  upper  surface 
of  the  scaphoid,  while  the  tibia  articulates  with  the  upper  surface  of  the 
os  calcis,  the  malleoli  being  abnormally  near  the  sole.  In  the  backward 
variety  the  astragalus  lies  between  the  tendo  Achillis  and  the  malleoli,  the 
relations  of  the  tibia  and  os  calcis  being  as  in  the  forward  variety.  The 
lateral  varieties  are  always  compound. 

Treatment.  Reduction  is  only  possible  in  the  incomplete  varieties,  and 
is  accomplished  by  traction  on  the  foot  writh  the  knee  flexed,  while  the  bone 
is  pushed  into  place.  The  complete  varieties  demand  open  operation  and, 
almost  certainly,  excision  of  the  bone,  wrhich  gives  a  very  useful  foot  in 
many  instances.  The  lateral  compound  dislocations  also,  in  most  cases,  call 
for  excision  of  the  astragalus. 

(e)  In  subastragaloid  dislocation  the  foot  below  the  astragalus  is  dis- 
placed, i.e.  the  dislocation  takes  place  at  the  astragalo-scaphoid  and  astragalo- 
calcaneal  joints.  The  displacement  is  alwrays  backward  and  also  laterally 
as  well.  In  either  case  the  fore-part  of  the  foot  is  short,  while  the  heel 
projects  ;  but  the  head  of  the  astragalus  forms  a  marked  projection  in  front 
of  the  malleoli,  and  this  normal  relation  of  the  astragalus  to  the  malleoli 
serves  to  diagnose  the  condition  from  a  dislocation  of  the  astragalus  with 
the  loot  from  its  socket.  Where  the  displacement  is  outward,  the  internal 
malleolus  projects,  while  in  the  converse  displacement  the  external 
malleolus  forms  the  projection.  In  either  instance  the  tendo  Achillis 
curves  to  the  side  of  dislocation,  and  in  the  outward  variety  the  foot  is 
in  a  position  ot  valgus,  while  in  the  opposite  displacement  is  that  of  varus. 

Treatment.  Traction  of  the  foot  with  the  knee  flexed  will  sometimes  be 
sufficient  ;  tenotomy  of  the  tendo  Achillis  may  be  indicated  or  division 
of  the  anterioi  tibial  tendons  if  these  entangle  the  head  of  the  astragalus. 
As  a  final  resort  excision  of  the  astragalus  may  be  needed. 


FRACTURE  OF  THE  OS  CALCIS 


345 


(g)  FRACTURES  OF  THE  BONES  OF  THE  FOOT 
The  astragalus,  os  calcis,  tarsal  scaphoid  and  the  metatarsals  demand 

attention. 

(1)  The  os  calcis  is  generally  broken  by  falls  on  the  feet  from  a  height, 

the  astragalus  being  driven  down  on  to  the  os  calcis,  which  gives  way  about 


Fig.  143.     Fracture  of  os  calcis.     Arrow  points  to  site  of  fracture  (X-ray). 


its  middle  (compression  fracture)  :  less  often  the  bone  is  broken  by  muscular 
violence,  the  powerfully  contracting  calf-muscles  pulling  off  the  posterior 
end  of  the  bone. 

Diagnosis.  In  the  compression  variety  there  will  be  swelling  and  bruising 
about  the  part  and  some  flattening  of  the  arch  of  the  foot ;  crepitus  is  rare, 
and  exact  diagnosis  impossible  without  radiographs.  In  the  variety  caused 
by  muscular  violence  the  loose  fragment  and  the  gap  caused  by  its  avulsion 
will  be  obvious. 

Treatment.  The  arch  of  the  foot  must  be  restored  by  manipulation 
under  anaesthesia  as  far  as  possible,  and  the  foot,  after  the  swelling  has 


346  \  TEXTBOOK  OF  SURGERY 

subsided,  put  up  in  a  divided  plaster-case  :    massage  may  be  commenced 

in  a  week  and  active  movements  of  flexion,  extension,  and  inversion  within 

fourteen  days.  The  plaster  may  be  omitted  in  lour  weeks,  but  the  patient 
should  place  no  weight  on  the  foot  for  at  leasl  two  or  even  three  months  and 
the  inner  side  of  the  sole  of  the  boot  should  be  thickened  a  quarter  of  an 
inch,  ami  a  valgus  brace  h:  uld  b'  worn  for  six  months  while  continuing 
exercises  to  prevent  the  onset  of  Hat -foot,  which  is  very  likely  to  follow 
this  injury.  In  the  variety  due  to  muscular  violence  the  fragment  must 
be  secured  in  position  by  open  operation  and  a  screw,  the  after-treatment 
being  as  before. 

(2)  Fractures  of  the  astragalus  are  also  due  to  falls  on  the  feet,  but  are 
less  common  than  those  of  the  former  bone;  sometimes  as  the  result  of 
these  accidents  both  astragalus  and  os  calcis  are  broken. 

The  displacement  is  often  slight,  but  if  the  fracture  is  due  to  crushing 
violence,  as  by  the  passage  of  a  wheel  over  the  ankle,  there  is  likely  to  be 
comminution  and  much  displacement. 

Diagnosis  from  sprains  is  often  impossible  without  radiographs  ;  some- 
times crepitus  on  lateral  movement  may  be  noted. 

Treatment.  Where  there  is  no  displacement,  or  where  the  latter  can 
be  reduced  by  forward  or  backward  traction  on  the  foot,  the  limb  should 
be  placed  on  Sharpe's  splint,  pulling  the  foot  forward  or  backward  by  the 
bandages  as  best  reduces  the  deformity.  Massage  may  be  used  in  a  week. 
and  after  fourteen  days  the  foot  may  be  placed  in  a  divided  plaster  and 
passive  movements  of  the  joint  commenced,  but  no  weight  should  be  taken 
on  the  foot  for  three  months.  In  badly  comminuted  cases  the  astragalus 
should  be  excised,  as  giving  a  more  hopeful  prospect  of  a  useful  ankle, 
which  if  splinted  under  such  conditions  is  likely  to  become  extremely  stiff. 

(3)  Fractures  of  the  tarsal  scaphoid  have  only  been  recognized  of  late 
with  the  more  careful  use  of  the  X-ray,  having  been  formerly  overlooked 
and  grouped  with  sprains  of  the  ankle.  The  condition  arises  from  twisting 
the  ankle,  and  the  tubercle  of  the  bone  is  broken  off,  resulting  in  limited 
] tower  of  inversion  of  the  foot  and,  later,  dropping  of  the  arch  (flat-foot). 

The  case  may  be  treated  on  a  Sharpe's  splint ;  if  the  fragment  is  not  well 
reduced  by  this  method  of  inversion,  the  fragment  should  be  affixed  with 
a  acrew.  The  after-treatment  is  directed  against  the  occurrence  of  flat- 
foot  as  described  in  the  treatment  of  Pott's  fracture  and  similar  lesions. 

(4)  Fractures  of  the  Metatarsals.  These  lesions  are  due  to  direct  violence, 
Buch  as  the  passage  of  a  wheel  over  the  foot,  and  the  first  and  fifth  are  the 
bones  most  commonly  broken. 

Signs.  These  are  swelling,  abnormal  mobility,  and  crepitus.  The 
displacement  is  usually  slight. 

Treatment.  As  soon  as  the  swelling  subsides  the  foot  may  be  placed  in 
divided  plaster  and  massage  employed  ;  no  weight  should  be  borne  by  the 
foot  for  one  to  two  months,  and  if  there  be  any  tendency  to  develop  flat- 
foot  this  should  be  corrected  early. 


CHAPTER  XIII 

DISEASES   OF   BONES,   JOINTS,   MUSCLES,    TENDONS   AND   BURS^E, 

AMPUTATIONS 

Anatomy  and  Growth  of  Bone  :  General  pathology  of  Bone  :  Congenital 
Affections  :  Rickets  :  Delayed  Rickets  :  Mollifies  Ossium  :  Infantile  Scurvy  : 
Acromegaly  :  Osteomalacia  :  Pulmonary  Osteo-arthropathy  :  Cretinism  : 
Osteitis  Deformans  :  Leontiasis  Ossea  :  Infective  disease  of  Bone  :  Pyogenic 
Infections  :  Periostitis  and  Diaphysitis  :  Juxta-epiphyseal  Infections,  Acute 
and  Chronic  (Brodie's  abscess)  :  Diaphysectomy,  Sequestrotomy  :  Tuberculosis 
and  Syphilis  of  Bone  :  Typhoid  infection  of  Bone  :  Hydatids  :  New  growths 
and  Cysts  of  Bone  :  Osteomas  :  Exostoses  :  Chondroma  :  Lipoma  :  Sarcoma  : 
Myeloid  Sarcoma  :  Operations  on  Bones  :  Repair  of  Defects  in  Bone. 
Joints  :  General  Considerations  and  Examination  :  Synovitis  :  Arthritis  : 
Ankylosis  :  Baker's  Cysts  :  Acute  Infections  :  Subacute  Infections  :  Tubercle 
and  Syphilis  :  Treatment  :  Arthrectomy  and  Excision  :  The  Rheumatoid 
Affections  :  Osteo -arthritis  :  Chronic  Gout  :  Charcot's  Joints  :  Hemophilic 
Joints:  Neoplasms  of  Join'- s  :  Functional  Affections  of  Joints  :  Operations  on 
Joints  :  Affections  of  Muscles  :  Paralysis  and  Spasm  :  Inflammations  : 
Myositis  Ossificans. 

Affections  of  Tendons    :    Acute  Tenosynovitis    :    Chronic  Tenosynovitis  and 
Ganglia  :  Operations  on  Tendon  and  Muscles  :  Bursitis. 

Amputations    :    General    Considerations    :    Technique    :    Various   Methods  : 
Artificial  limbs. 

AFFECTIONS  OF  BONE 

Anatomy  and  Physiology.  In  a  young  subject  (and  the  most  important 
diseases  of  bones  are  those  occurring  in  young  subjects)  a  long  bone  con- 
sists of  a  covering  of  periosteum,  a  diaphysis  (which  is  a  tube  of  dense 
bone  in  its  greater  extent  but  fashioned  of  cancellous  bone  at  the  ends), 
and  an  epiphysis  formed  of  cancellous  bone  at  one  or  more  usually  both, 
ends  of  the  diaphysis,  separated  from  the  diaphysis  by  a  layer  of  ossifying 
cartilage  which  is  responsible  for  the  growth  of  the  bone.  The  cancellous 
bone  is  filled  with  red  marrow,  while  the  hollow  of  the  shaft  contains  more 
fatty  yellow  marrow.  The  periosteum  at  each  end  covers  the  line  of  the 
epiphyseal  cartilage  (which  intervenes  between  the  epiphysis  and  diaphysis) 
and  is  more  firmly  attached  to  the  epiphysis  and  the  ligaments  of  the  joint, 
of  which  the  epiphysis  forms  part,  than  to  the  diaphysis,  from  which  it 
strips  readily. 

The  nutrient  vessels  enter  the  bone  not  only  by  the  large  nutrient  fora- 
mina in  the  centre  of  the  shaft  but  also  all  over  the  surface  from  the  periosteal 
covering,  the  smaller  vessels  lying  in  the  spaces  of  the  cancellous  bone  and 
in  the  Haversian  canals  of  the  dense  bone  of  the  diaphysis. 

The  cells  of  bone  are  of  two  varieties  :  the  smaller  spindle-shaped  osteo- 
blasts, lying  along  the  deep  surface  of  the  periosteum,  in  the  canaliculi, 
around  the  Haversian  canals,  and  in  the  spaces  of  the  cancellous  bone,  have 

347 


A  TEXTBOOK  OF  SURGERY 

the  property  of  laying  down  new  bone ;  while  the  larger  multinucleate  osteo- 
clasts are  found  where  bone  is  being  absorbed  and  are  the  active  agents  in 
this  process.  The  red  marrow  is  important,  qoI  only  in  producing  and 
absorbing  bone  bul  also  in  the  formation  of  red  corpuscles  and  Leucocytes, 
and  therefore  plays  a  very  prominent  pari  in  t  be  pathology  of  infections,  &c. 
Growth  of  Bone.     This  takes  place  : 

(1)  At  the  ends,  from  ossification  of  the  epiphyseal  cartilage  on  its 
diaphyseal  side  :  very  little  growth  takes  place  on  the  epiphyseal  side  of 
the  cartilage.     In  this  manner  the  bone  grows  in  Lou////. 

(2)  Growth  in  Width  takes  place  by  the  laying  down  of  new  bone  by 
the  osteoblasts  in  the  deeper  layer  of  the  periosteum  (it  is  immaterial 
whether  we  consider  this  layer  to  be  the  most  superficial  layer  of  the  bone 
or  the  deeper  layer  of  the  periosteum)  ;  at  the  same  time  the  inside  of  the 
hollow  shaft  of  the  bone  is  removed  by  osteoclasts,  so  that  the  thickness 
of  the  tube  does  not  increase  very  rapidly.  These  processes  also  proceed 
at  the  ends  of  the  diaphysis  so  that  the  cancellous  bone  retains  its  relative 
proportion  to  the  whole  bone. 

The  osteoblasts  in  the  canaliculi,  Haversian  canals,  and  spaces  of  the 
cancellous  bone  may  lay  down  new  bone,  increasing  its  Density,  and  this 
process  may  be  of  physiological  or  pathological  significance. 

General  Pathology  of  Bone.  The  processes  of  disease  have  much 
in  common  with  those  of  growth.  Thus  as  the  result  of  irritation,  whether 
tnicrobic,  nutritional  or  neuropathic,  there  may  be  an  increased  laying 
down  of  new  bone  on  the  surface  or  in  the  substance  of  the  existing  bone, 
the  result  being  essentially  an  increase  in  the  density  of  the  bone  affected. 
Such  a  change  is  described  as  Sclerosis,  sometimes  as  hypertrophy,  though 
the  latter  term  is  more  correctly  applied  to  increase  in  density  of  bone 
from  increased  physiological  use.  Where  the  irritant  is  more  severe,  osteo- 
clasts are  more  in  evidence,  the  bone  is  excavated  and  becomes  porous, 
lighter,  weaker,  and  less  dense.  Such  changes  are  found  not  only  to  result 
from  infections,  but  also  from  constitutional  or  nutritional  diseases  such 
as  rickets,  and  are  known  as  Osteoporosis  or  Rarefaction,  or  less  correctly  as 
atrophy.  If  the  causal  agent  is  microbic  the  term  Caries  is  applied  to  the 
resulting  condition,  which  is  of  very  similar  nature.  Alterations  and 
deficiencies  may  also  occur  in  the  cartilage  at  the  epiphyseal  line,  which 
becomes  irregular,  and  the  growth  of  bone  suffers  in  consequence.  Where 
the  irritation  is  very  gross  the  structure  of  bone  leads  to  special  results  : 
the  density  of  the  tissue  prevents  expansion  when  inflammatory  exuda- 
tion is  poured  out ;  the  periosteum,  which  bears  many  of  the  nutrient  vessels 
to  the  bone,  is  readily  stripped  up  by  such  exudation  and  the  nutrient 
Is  torn,  pressed  on,  or  thrombosed — the  result  in  either  case  being  to 
<ut  ofi  the  blood-supply  of  the  bone  and  that  a  large  area  will  die.  When  a 
considerable  max  of  bone  dies  in  this  manner  the  process  is  called  Necrosis 
and  the  dead  portion  is  called  a  Sequestrum.  Necrosis  is  closely  allied  to 
sloughing  and  gangrene  in  the  soft  tissues,  and  is  characteristic  of  very 
acute  inflammations  of  bone. 


GENERAL  PATHOLOGY  OF  BONES         349 

Atrophy  and  Hypertrophy  of  Bone.  The  term  atrophy  is  applied 
to  changes  of  bone  of  a  rarefactive  nature  occurring  apart  from  inflamma- 
tion, and  is  found  in  : 

(a)  Old  age  ;   e.g.  the  skull,  jaw,  neck  of  the  femur,  ribs,  &c. 

(b)  In  affections  of  the  nervous  system  ;   e.g.  tabes,  general  paralysis. 

(c)  From  disuse,  as  in  paralysed  limbs  or  those  which  have  been  confined 
in  splints  for  some  time ;  atrophy  of  the  orbit  after  excision  of  the  eye  in 
young  persons,  &c. 

(d)  From  local  pressure,  especially  from  that  of  a  neighbouring  aneurysm, 
but  also  from  other  tumours  growing  in  close  proximity  to  bones. 

(e)  From  interference  with  the  growing  epiphyseal  line  due  to  rickets, 
injury,  &c,  these  conditions  being  closely  allied  to  inflammation. 

Hypertrophy.  Apart  from  inflammation  true  hypertrophy  is  uncommon 
and  may  result  from  : 

(a)  Overuse,  as  in  the  ridges  on  the  bones  of  muscular  individuals  or 
the  buttresses  forming  in  the  callus  of  badly  set  fractures  ;  such  hyper- 
trophies are  protective  and  almost  physiological. 

(b)  From  increased  blood-supply  ;  thus,  as  a  sequel  to  inflammation 
there  may  occasionally  be  overgrowth  of  the  bone. 

(c)  Congenital,  as  in  gigantism,  whether  local  or  general. 

(d)  In  certain  general  diseases,  e.g.  acromegaly. 

The  terms  excentric  and  concentric  are  applied  both  to  atrophy  and 
hypertrophy — the  former  meaning  that  the  alteration  is  on  the  outside,  the 
latter  that  it  is  on  the  inside  of  the  bone. 

Diseases  of  Bone.  These  are  many  in  number,  but  several  are  only 
of  pathological  interest,  while  others  belong  rather  to  internal  medicine 
than  surgery  and  will  be  dismissed  with  brief  notice  to  make  the  survey 
complete. 

Diseases  of  bones  may  be  divided  as  follows  : 

(1)  Congenital  defects  of  bone  formation. 

(2)  Diseases  due  to  faulty  nutrition  and  hygiene  (rickets,  scurvy). 

(3)  Diseases  of  constitutional  origin,  secondary  to  disease  of  other 
organs,  from  involvement  of  internal  secretions  (acromegaly). 

(4)  Inflammations,  infections,   including  the   effects  of  parasites  and 
injuries. 

(5)  Neoplasms  and  cysts  of  bone. 

The  last  two  groups  are  of  by  far  the  most  importance  to  the  practical 
surgeon,  for  with  the  exception  of  the  changes  due  to  rickets  the  rest  may 
be  regarded  as  pathological  freaks  and  curios. 

Examination  of  Cases  of  Bone  Affections.  The  function  of  the 
part  involved  should  be  examined  if  the  lesion  be  not  too  acute  ;  e.g.  gait, 
power  of  moving  joints,  &c. 

The  part  affected  should  be  examined  for  local  swelling,  whether  diffuse 
or  circumscribed,  the  former  suggesting  growth,  the  latter  inflammation  ; 
also  whether  the  swelling  involves  the  whole  bone  or  a  part  only,  the  former 
suggesting  that  the  disease  originates  in  the  interior  of  the  bone  (endosteal). 


350 


\  TEXTBOOK  <>K  SURGERY 


Softness,  fluctuation,  01  crackling  of  the  surface  of  the  swelling  will  be 
noted,  as  well  as  oedema,  redness,  or  other  signs  of  inflammation. 

Abscesses  al  a  distance  should  be  looked  for,  and  conversely,  if  large 
cold  abscesses  are  noted,  search  should  be  made  for  old-standing  bone 
disease.  Psoas  or  lumbar  abscesses,  from  disease  of  the  spine,  are  instances 
in  point.  Sinuses  should  be  examined  with  sterile  probe  for  hare  smooth 
or  crumbling  carious  hone  or  loose  sequestra,  and  injection  with  bismuth 

paste,  30  per  cent,  in  vaselin  (Beck). 
followed  by  an  X-ray  examination,  will 
often  help  in  tracking  such  sinuses  to 
their  origin. 

The  underlying  cause  of  the  disease 
i-  sought  by  examining  for  evidence  of 
syphilis,  tuberculosis,  rickets,  scurvy, 
gout,  infective  diseases,  e.g.  furuncles, 
specific  fevers  (typhoid,  scarlatina), 
while  mercurial  or  phosphorous  poison- 
ing must  not  he  overlooked,  nor  nervous 
diseases  such  as  tabes. 

The  general  condition  is  noted  as 
to  evidence  of  metastatic  disease,  as 
evidenced  by  rigors,  pysemic  abscesses, 
broncho-pneumonia,  diarrhoea,  albumi- 
nuria. &c. 

(1)  Affections  of  Bone  of  Con- 
genital Origin.  Bones  may  be  affected 
congenitally  in  (a)  size,  (b)  shape,  (c)  number,  and  (d)  structure. 

(a)  As  regards  size  the  bones  may  be  generally  or  locally  affected.  A 
general  overgrowth  of  bones  outside  normal  limits  is  called  gigantism  (to 
be  distinguished  from  the  overgrowth  of  acromegaly). 

Gigantism  may  affect  a  limb  or  part  of  it  or  the  whole  body.  When 
digits  are  enlarged  in  this  manner  the  condition  is  described  as  macro- 
dactyly  :  when  a  limb  is  involved  the  change  is  called  macro-melia.  The 
converse  congenital  disorder  of  growth  is  called  dwarfism,  and  this  may 
also  be  of  the  whole  body  or  confined  to  some  portion.  In  general  dwarfism 
the  whole  body  is  on  a  small  scale  but  the  parts  are  in  proportion, 
and  so  distinguished  from  the  dwarfing  in  cretinism  and  achondroplasia, 
where  the  deficiencies  are  local  and  the  head,  limbs,  and  body  out  of 
proportion. 

(b)  The  shape  of  bones  may  be  congenitally  abnormal  without  their 
structure  being  obviously  deficient.  Thus  failure  to  unite  on  the  part  of 
the  vertebral  lamina)  or  skull  leads  to  the  defects  known  as  meningocoeles, 
&c.  (in  these  cases  we  should  perhaps  be  more  correct  in  regarding  the  bony 
defec  ondary  to  the  deficiency  in  the  nervous  system);  congenital 
dislocations  and  deformities  such  as  club-foot  are  more  properly  placed  in 
this  category. 


FlG.    144.     Polydactyly. 


GENERAL  PATHOLOGY  OF  BONES          35 J 

(c)  The  number  of  bones  may  be  abnormally  increased  or  deficient,  as, 
for  example,  supernumerary  digits,  cervical  ribs,  &c.   (Fig  144.) 

(d)  Congenital  abnormality  in  structure  includes  a  number  of  conditions, 
and  it  will  be  sufficient  to  refer  to  two  types,  achondroplasia  and  osteo- 
genesis imperfecta. 

(1)  In  Achondroplasia  there  is  deficient  power  of  growth  in  the  epiphyseal 
cartilage  of  the  long  bones  and  elsewhere.  The  layer  of  cartilage  is  reduced 
in  thickness,  the  growth  is  slow  and  the  limbs  are  stunted  in  length. 
The  legs  are  very  short  but  not  bent  as  in  rickets  and  cretins,  while  the 
arms  are  also  reduced  in  length,  the  hands  not  reaching  below  the  iliac 
crest.  The  base  of  the  skull  is  defective  in  growth,  so  that  the  vault  is 
disproportionately  large  and  the  nose  sunken.  Intelligence  is  normal  and 
muscular  power  good.  The  fingers  taper  to  their  extremities,  having  a 
"  spoke-like  "  appearance  ;  lordosis  is  usual.  The  very  short  limbs  and 
large  vertex  cranii  are  characteristic  of  this  condition.    (Fig.  150  B.) 

(2)  In  Osteogenesis  Imperfecta  the  formation  of  bone  in  the  primitive 
cartilage  of  the  diaphysis  of  long  bones  is  incomplete  and  islands  of  cartilage 
remain,  the  bones  being  fragile,  readily  breaking  and  undergoing  degene- 
rations. It  is  possible  that  more  than  one  condition  is  included  under  this 
term.  The  main  feature  of  these  cases  is  the  great  liability  to  fracture  of 
the  limbs,  of  which  as  many  as  twenty  to  thirty  may  occur,  leading  to 
great  deformity,  as  the  repair  of  these  bones  is  not  good,  the  amount  of 
callus  being  excessive  to  a  gross  degree.  In  radiograms  the  bone  may  be 
noted  as  a  large  spongy  meshwork  many  times  the  diameter  of  the  normal 
bone,  round  which  the  soft  tissues  are  swollen  up  and  covered  with  dilated 
veins  (we  have  seen  the  humerus  in  a  small  child  with  a  circumference  of 
eighteen  inches  in  a  case  of  this  nature).  The  appearance  of  such  large 
ovoid  tumours  covered  with  veins  suggests  the  diagnosis  of  sarcoma,  and 
in  some  instances  this  may  be  the  true  nature  of  the  condition,  but  as  a 
rule  it  will  subside,  leaving  a  deformed  limb  :  the  disease  is  distinctly  familial, 
running  through  several  generations  of  a  family.  Slighter  instances  of 
"  fragilitas  ossium,"  where  fracture  occurs  readily  but  without  such  marked 
changes  in  the  bones,  may  be  milder  degrees  of  this  disease.  The  tumours 
forming  about  the  fractures  are  to  be  regarded  as  superabundant  callus 
formed  with  excessive  freedom.    (Figs.  145.  146.) 

(2)  Affections  of  Bone  due  to  Faulty  Nutrition  and  Hygiene. 
In  this  group  are  included  rickets,  infantile  scurvy,  delayed  rickets,  and 
molities  ossium  of  adolescents. 

(a)  Rickets  (rhachitis).  This  disease  is  caused  by  faulty  hygiene  of  all 
sorts  :  want  of  air,  sunlight,  deficient  cleanliness,  but  above  all  improper 
nourishment,  the  food  being  deficient  in  fats,  proteids,  and  lime-salts. 
The  disease  usually  starts  in  the  second  year  of  life,  and  rickets  is  uncommon 
in  infants  while  breast-fed,  but  if  the  mother  is  ill -nourished  or  if  her  health 
is  depressed  by  general  disease,  repeated  pregnancies  or  prolonged  lactation, 
the  breast-fed  infant  may  develop  rickets.  The  food  of  the  infant  must 
not  only  contain  the  proper  amounts  of  fats  and  proteids  and  salts,  but 


A  TEXTBOOK  OF  SURGERY 


also  these  must  be  in  a  Biiitable  condition  Eor  assimilation:  hence  the 
disease  is  most  ofteD  found  in  infants  fed  on  patent  foods,  in  which  one  or 
more  of  these  constituents  is  often  markedly  deficient.  The  excess  of 
starch  in  most  of  these  patent  foods  produces  intestinal  disturbance  and 
prevents  the  absorption  of  the  other  constituents  even  if  they  are  present. 


Fig. 


I  \:,.    Osteogenesis  imperfecta.     Skiagram  of  lower  limb.     Bending  and  result  of 

previous  fra«  I  ores  is  seen. 

[Kindly  lent  by  Mr.   A.. J.  ]Y  niton.) 


Caieml  S'kjus  of  Rickets.  These  are  irritability,  sleeping  badly,  nocturnal 
pyrexia  of  moderate  degree  with  sweating,  especially  of  the  head.  The 
child  is  anaemic  and  flabby  and  may  be  fat  or  wasted.  Gastrointestinal 
disturbance,  vomiting,  diarrho-a  with  green  stools  are  common.  In  the 
more  severe  cases  the  limbs  are  feeble,  paretic,  the  abdomen  protuberant, 
the  liver  and  spleen  enlarged, 


RICKETS 


353 


Skeletal  Changes  in  Rickets.  The  underlying  changes  are  those  of 
improper  formation  of  bone  associated  with  an  unhealthy  vascularity  of 
the  growing  portions.  In  the  dense  parts  of  the  shafts  of  the  long  bones 
and  in  the  flat  bones,  e.g.  of  the  skull,  absorption  of  bone  goes  on  too 
rapidly,  while  there  is  deficient  calcification  of  the  newly  formed  bone, 


Fig.  146.     Osteogenesis  imperfecta.     Skiagram  showing  large  excess  of  callus 

following  a  fracture  of  femur  which  simulates  a  sarcoma. 

[Kindly  l<  nt  by  Mr.  F.  S.  Kidd.) 

the  Haversian  canals  and  cancellous  spaces  being  too  large.  In  the  forma- 
tion of  bone  from  cartilage  at  the  epiphyseal  line  there  is  a  want  of  regularity 
in  the  columns  of  cartilage  cells,  the  process  of  ossification  is  irregular 
and  deficient,  the  newly  formed  bone  being  mixed  up  with  islands  of  carti- 
lage left  behind  in  the  process.  The  result  of  these  changes  is  limited 
growth  and  widening  of  the  epiphyseal  ends  of  the  bone,  while  as  a  whole 
the  bone  is  short,  stunted,  and  tends  readily  to  bend,  giving  rise  to  the 
deformities  typical  of  the  disease.  On  longitudinal  section  through  the  end 
i  23 


:;:,! 


A  TEXTBOOK  OF  SURGERY 


of  the  bone  the  epiphyseal  line  appears  wide  and  irregular.  Calcium  salts 
are  greatly  deficient  in  the  bone;  the  distinction  between  compad  and 
cancellous  bone  becomes  less  marked  than  normal,  the  bone  being  spongy 
and  soft.     (Fig.  147.) 

Deformities  arising  from  Improper  Ossification  in  Rickets.     The 
Skull.    The  fontanelles  close  late,  sometimes  not  till  two  to  three  years 

(instead    of    one  and  a  half  years),  the  hones  of  the  cranium  being  thin  and 


£  Fig.   147.     Genera]  valgum,  due  to  rickety  curvature  of  femora 
and  tibiae  (skiagram). 

parchment-like.  There  is  excessive  formation  of  bone  in  the  frontal  and 
parietal  eminences,  giving  the  skull  a  square  appearance,  while  the  growth 
of  the  cranium  is  faster  than  that  of  the  face,  giving  the  semi  .lane.'  of  a 
minor  degree  of  hydrocephalus. 

The  thin  soft  condition  of  the  skull,  which  may  be  indented  by  the 
finger,  is  known  as  "  cranio-tabes,"  to  be  distinguished  from  that  of  con- 
genital syphilis. 

7  he  Teeth.  These  are  erupted  late,  are  badly  formed  and  decay  early, 
but  there  is  no  resemblance  to  the  notched  teeth  of  congenital  syphilis. 

Spine.  This  becomes  kyphotic  or  kypho-scoliotic  if  the  rickety  infant 
is  allowed  to  si1  or  stand. 

7  Jwrax.  The  enlargement  of  the  growing  point  of  the  ribs  at  the  costo- 
chondral  junction  (the  rib  epiphysis)  gives  rise  to  the  well-known  "  beading  " 


THE  BONES  IN  RICKETS  355 

of  the  ribs  or  "  rickety  rosary."  The  softened  bones  of  the  thorax  are 
drawn  inward  by  the  negative  pressure  of  the  pleural  cavity  on  either  side 
of  the  sternum,  which  relatively  projects  forward,"  pigeon  breast." 

The  liver  prevents  the  in-drawing  of  the  lower  part  of  the  thorax,  which 
becomes  folded  transversely  at  the  lower  end  of  the  sternum  ("  Harrison's 
sulcus  ").  The  deformities  of  the  thorax  are  increased  by  naso-pharyngeal 
obstruction  from  adenoid  vegetations,  &c,  which  are  common  in  such 
children. 

The  Pelvis.  While  the  infant  is  recumbent  the  pelvis  is  simply  flattened 
from  before  backwards,  the  sacrum  projecting  into  the  cavity  of  the  true 
pelvis,  giving  it  the  "  reniform  "  shape.  If  the  child  can  stand  or  walk 
while  the  bones  are  in  this  soft  state  the  acetabula  in  addition  are  driven  in- 
wards by  the  pressure  of  the  femora  on  either  side,  producing  the  "  beaked  " 
or  "  triradiate "  pelvis  so  characteristic  of  osteomalacia.  These  pelvic 
deformities  concern  the  obstetrician,  from  increasing  the  difficulty  of  labour. 

Lower  Limbs.  When  the  weight  of  the  body  is  taken  on  the  softened 
leg  bones  the  angle  of  the  neck  of  the  femur  becomes  diminished  to  a  right- 
angle  or  less  (rickety  coxa  vara).  The  limb  as  a  whole  becomes  bowed 
outward  so  that  the  knees  are  widely  separated  when  the  legs  are  extended, 
in  severe  cases  giving  the  appearance  of  an  0.  This  deformity  is  caused 
by  outward  bowing  of  both  the  femur  and  tibia  (genu  varum).  In  other 
cases  there  is  bowing-in  of  the  knee  (genu  valgum)  ;  while  not  infrequently 
there  is  bowing-out  of  the  femur  and  bowing-in  of  the  tibia. 

The  tibiae  begin  to  bend  as  the  child  crawls,  the  extended  foot  exerting 
a  tension  backwards  and  inwards  on  the  lower  end  of  the  tibia,  causing  a 
bowing  outward  and  forward  in  the  lower  half  of  the  bone,  which  is  increased 
as  the  child  stands  on  the  limb. 

As  the  disease  subsides  the  bones  become  more  dense  and  hard  than 
normal ;  the  exaggerated  curves  persist  unless  corrected,  and  there  remains 
a  stunted,  clumsy,  but  sturdy  limb. 

Treatment.  This  concerns  (a)  the  disease  in  general  and  (b)  the  prevention 
or  correction  of  the  skeletal  deformities.  Fresh  air,  sunlight,  attenlion  to 
clothing  (which  generally  means  reducing  its  amount)  are  important ;  the 
diet  must  be  revised  ;  plenty  of  milk,  diluted  if  necessary,  meat  juice,  later, 
sound  fruit,  e.g.  bananas,  orange-juice,  and  fatty  foods,  bacon,  eggs  are  given, 
while  the  amount  of  starchy  matters  ingested  should  be  reduced.  Of  drugs, 
cod-liver  oil  and  the  syrup,  ferri.  phosph.  co.,  separately  or  together,  are 
excellent. 

Deformities  are  obviated  by  keeping  the  child  recumbent  and  preventing 
walking  by  splints  which  extend  below  the  foot.  The  patient,  however, 
must  on  no  account  be  fixed  in  one  posture,  but  frequent  change  of  position 
and  massage  of  the  whole  body,  removing  splints  for  this  purpose,  play  an 
important  part  in  the  treatment  of  rickets.  Attention  should  be  directed 
to  the  naso-pharynx,  tonsils  and  adenoids  removed  if  necessary,  and  breath- 
ing exercises  practised  to  maintain  a  proper  shape  of  the  thorax.  Treatment 
of  deformities  is  further  considered  in  the  deformities  of  regions. 


\  TEXTBOOK  OF  SURGERY 


(}>)  Lull  or  l>t  hi ijul  Rickets.  This  is  an  uncommon  condition,  coming 
on  from  sewn  to  ten  years  of  age,  with  enlargement  of  the  epiphyses  and 
uing  ami  bending  of  the  bones.  The  general  irritability,  sweats, 
enlargement  of  the  liver  and  spleen  arc  not  found,  so  that  the  relation 
of  this  disease  to  ordinary  rickets  is  uncertain.  Treatment  on  the  lines 
indicated  for  ordinary  rickets  is  successful. 

MoUities  Ossium  <>f  Adolescents.     This  is  a  common  condition,  the 
underlying  tart   being  that  the  bones  are  not  strong  enough  to  bear  the 


I'n..   J4s.     Infantile  .-curvy.     Skiagram  showing  large  Bubperiosti  a]  hapmorrhage  of 

one  femur  and  a  smaller  "in-  ol  the  other. 

(Kindly  lent  by  Mr.  .1.  ./.  Walton.) 

weight  of  the  rapidly  growing  patient.  The  results  of  this  condition  are 
therefore  noted  in  the  legs,  as  the  softening  of  the  bones  is  not  great,  and 
unless  subjected  to  considerable  strains,  as  in^the  legs  of  rapidly  growing 
children  and  youths  who  have  to  stand  for  long  periods,  no  deformity 
results.  It  i-  <|uestionable  if  this  condition  has  any  relation  to  true  rickets, 
but  tin'  bones  show  rarefactive  changes  and  insufficientcalcification(Keetley). 
I  here  is  usually  a  general  flabbiness  of  muscular  tone  in  these  individuals, 
or  they  are  too  early  obliged  to  carry  heavy  weights  or  stand  for  many 
hours  at  a  Btretch.     The  resulting  deformities  are  coxa  vara,  genu  valgum, 


INFANTILE  SCURVY  357 

scoliosis  and  flat-foot,  and  treatment  is  rather  needed  for  the  particular 
deformity  resulting  than  for  the  underlying  condition  of  the  bone. 

(d)  Infantile  Scurvy  (scurvy-  or  hsemorrhagic  rickets,  Barlow's  disease). 
This  occurs  in  infants  of  from  four  to  ten  months  old,  and  is  due  to  improper 
feeding  on  artificially  prepared  foods,  especially  if  sterilized,  and  is  there- 
fore akin  to  scurvy  of  adults.  The  infant  is  found  to  be  irritable,  especially 
if  the  lower  limbs  are  moved,  and  lies  with  these  everted  and  immobile  in  a 
condition  of  pseudo-paralysis  owing  to  the  pain  caused  by  their  movement. 
At  the  same  time  swellings  appear  along  the  diaphyses  of  femur  and  tibia. 
Later  weakness  of  the  back  is  noted  and  swellings  appear  along  the  bones  of 
the  forearms  above  the  wrists.  The  joints  are  not  affected  (distinguishing 
from  epiphysitis,  arthritis,  &c.)  The  swellings  along  the  shafts  of  the 
bones  are  due  to  extravasations  of  blood  beneath  the  periosteum,  which 
is  stripped.  Separation  of  the  epiphysis  from  the  diaphysis  in  consequence 
of  the  extravasated  blood,  with  crepitus,  may  take  place  at  the  lower  end 
of  the  femur  or  upper  end  of  the  tibia.  Proptosis  from  haemorrhage  into 
the  orbit  sometimes  occurs.  As  the  case  advances  there  is  increasing 
anaemia,  till  the  colour  becomes  earthy  ;  irregular  pyrexia  and  subcutaneous 
ecchymoses  and  bruises  may  be  noted.  Sponginess  of  the  gums  is  only 
present  when  the  teeth  have  been  cut,  which  is  not  usual  in  these  young 
infants. 

Diagnosis.  This  has  to  be  made  from  syphilitic  epiphysitis,  which  occurs 
at  about  the  same  period  of  life,  by  the  swelling  in  the  latter  condition  being 
close  to  the  epiphysis  and  not  along  the  shaft  of  the  bone,  and  by  the  latter 
condition  readily  going  on  to  suppuration.  The  history  of  improper  feeding 
and  the  absence  of  a  Wassermann  reaction  or  other  signs  of  syphilis  will 
exclude  the  latter.  From  sarcoma,  the  multiplicity  of  the  lesions,  the 
irritability,  the  rapid  onset,  pseudo-paralysis,  and  inquiry  into  the  method 
of  feeding  will  easily  separate  this  condition. 

Treatment.  The  addition  of  fresh-meat  juice,  orange  juice,  or  crushed 
banana  to  the  diet  will  soon  cure  the  condition. 

(3)  Affections  of  Bone  of  Constitutional  Origin.  In  this  group 
are  included  acromegaly,  osteomalacia,  pulmonary  osteo-arthropathy, 
cretinism,  osteitis  deformans,  and  leontiasis  ossea — the  last  two  conditions 
being  of  unknown  origin,  the  others  being  secondary  to  disease  elsewhere, 
dependent  on  alterations  or  deficiencies  of  internal  secretions. 

(a)  Acromegaly.  The  enlargement  of  the  extremities  implied  by  the 
name  of  this  disease  is  found  in  the  hands,  feet,  and  jaws  of  adults.  The 
underlying  cause  of  the  affection  seems  to  be  a  hypertrophy  of  the  pituitary 
body,  which  through  its  internal  secretion  would  appear  to  regulate  the 
growth  of  bone.  In  some  instances  when  the  pituitary  body  is  affected  in 
early  life  the  result  is  gigantism  of  the  individual,  and  it  is  recognized  that 
in  the  skulls  of  many  giants  the  pituitary  fossa  is  disproportionately  large, 
while  certain  of  these  giants  in  later  life  develop  acromegaly.     (Fig.  150  A.) 

In  acromegaly,  which  is  more  common  in  women,  the  bones  of  the 
hands  and  feet  become  greatly  enlarged,  especially  in  thickness,  the  length 


A  TEXTBOOK  OF  SURGERY 

being  little  increased.  The  handa  thus  become  spade-like,  and  the  fingers 
have  been  compared  to  bunches  of  sausages.  The  jaws,  but  especially  the 
lower,  undergo  increase  in  size,  giving  the  patient  a  remarkable  prognathous 
and  underhung  appearance.  The  orbital  ridges  project,  the  skin  of  the 
face,  uose,  and  lips  is  thickened,  and  the  under-lip  protrudes.    (Fig.  149.) 

The  duration  of  the  disease  varies,  in  some  instances  running  a  course 
nt  many  years,  with  but  slighl  increase  in  severity  of  the  signs.     In  other 


FlO.    140.     Acromegaly.     J\ote  the  enlarged  nose,  lips,  and  lower  jaw,  as  well  as 

the  clumsy  ringers. 

instances,  however,  signs  of  increased  intracranial  pressure  are  found,  such 
as  headache  and  vomiting,  while  the  pressure  of  the  tumour  on  the  neigh- 
bouring  optic  chiasms  leads  to  bi-temporal  hemianopsia  with  optic  atrophy, 
optic  neuritis  being  unusual. 

In  the  earlier  stages  the  muscular  power  may  be  great,  but  later  wasting 

and  weakness  ensue. 

Treatment.  Where  signs  of  intracranial  pressure  are  not  present  no 
treatment  is  indicated,  but  where  there  is  pressure  on  the  brain  or  optic 
1  ract  the  hypophysis  should  be  exposed  and  the  tumour  removed  if  possible 
erebral  Tumours). 

(6)  Ost  omalacia.  This  disease  is  characterized  by  a  general  rarefaction 
and  decalcification  of  the  bones,  leading  to  considerable  softening  of  certain 
"f  the  osseous  structures.     It  occurs  mostly  in  puerperal  women,  especially 


INFANTILE  SCURVY 


359 


in  certain  valleys  in  the  Rhine  district.  The  softening  process  affects  first 
and  chiefly  the  spine  and  pelvis,  so  that  the  former  takes  on  a  severe  kypho- 
scoliotic  curve,  the  latter  assumes  the  triradiate  shape.  The  bones  of  the 
limbs  are  less  affected.  The  disease  recurs  with  each  pregnancy  and  lacta- 
tion, and  the  bones  be- 
come recalcified  in  the 
intervening  periods. 

Treatment.  The  avoid- 
ance of  future  pregnancies 
or  cutting  the  present  one 
short,  if  the  softening  and 
bending  of  the  bones  are 
very  severe,  is  indicated. 
The  disease  also  ceases  at 
the  climacteric,  whether 
natural  or  produced  by 
oophorectomy. 

Other  conditions  de- 
scribed as  osteomalacia 
are  found  in  aged  persons, 
especially  if  insane,  and 
occasionally  in  girls  about 
puberty.  But  in  these 
conditions  the  bones  are 
rather  extra  fragile  and 
liable  to  multiple  fractures 
than  soft  and  inclined  to 
bend,  as  in  the  puerperal 
form. 

(c)  Hypertrophic  Pul- 
monary Osteo  -  arthropath  y . 
The  length  of  the  name 
is  inversely  proportional  to 
the  importance  of  this  dis- 
ease. The  curved,  bulging  nails  associated  with  chronic  heart  and  lung  disease 
have  been  noted  since  the  days  of  Hippocrates.  The  condition  described  here 
is  an  exaggeration  of  the  latter  affection.  The  terminal  phalanges  of  the  fingers 
are  enlarged  and  in  some  instances  the  lower  ends  of  the  radius  and  ulna  as 
well,  while  kyphosis  may  be  noted.  The  disease  is  distinguished  from 
acromegaly  by  only  the  last  phalanges  and  wrist  being  enlarged,  the  rest 
of  the  hand  escaping,  while  the  face  and  jaw  are  unaffected,  nor  are  there 
any  signs  of  pressure  on  the  optic  tract  or  brain  ;  instead  there  will  befound 
chronic  lung  disease  such  as  bronchiectasis,  fibrous  pleurisy,  long-stand- 
ing empyema,  tuberculosis,  &c.  Periostitis  of  the  phalanges  arising  in 
the  workers  in  mother-of-pearl  in  Vienna  seems  to  be  of  closely  allied 
nature. 


Fig.  150 


A  B 

.     A,  Gigantism  with  pituary  enlargement. 

B,  Achondroplasia. 
(Kindly  lent  by  Mr.  Robert  Milne.) 


A  TEXTBOOK  OF  SURGERY 


(,/  Disease  of  the  thyroid  gland  in  early  life  upsets  the 

formation  of  bone,  resulting  in  a  dwarfed  condition   of   the   patient    due 
to   want    of   growth   oi   the   epiphyseal  ends  oi  the  bones,  which  remain 

ill  developed  and  unossified  late  in 
life. 

(e)  Infantilism  or  dwarfism,  asso- 
ciated with  imperfect  development 
of  the  sexual  organs,  demands  but 
a  passing  mention. 

(f)  Osteitis  Deformans.  'This  dis- 
ease, first  described  by  Paget,  is  of 
unknown  origin  and  is  characterized 
by  a  thickening  of  the  long  bones, 
which  become  at  the  same  time  bent, 
and  a  thickening  of  the  bones  of  the 
cranium.  The  bones  affected  show 
a  mixture  of  rarefying  and  sclerosing 
osteitis,  becoming  more  spongy  and 
weaker,  though  thicker,  and  not  in- 
frequently in  the  later  stages  are  the 
seat  of  sarcomatous  growths.  The 
condition  originates  in  middle  life 
with  pains  in  the  legs,  which  become 
bent ;  the  angle  of  the  femoral  neck 
becomes  diminished  and  the  bowing 
of  the  femur  and  tibia  leads  to 
marked  genu  varum. 

Kyphosis  is  generally  consider- 
able, but  a  still  more  notable  feature 
is  the  increase  in  size  of  the  cranium, 
due  to  thickening  of  the  cranial 
bones,  necessitating  the  procuring 
of  increasingly  larger  hats.  The 
facial  bones  remain  unaffected. 
The  duration  of  this  disease  is  long, 
death  occurring  alter  many  years 
1 1 < mm  the  sarcomas  mentioned  al- 
ready oi-  heart,  lung,  or  kidney  complications. 

Diagnosis.     This  is  made  from  arthritis  deformans,  in  which  the  attitude 

and  gait  are  similar,  by  the  absence  of  articular  changes  and  the  enlarge- 
ment ot  the  cranium  ;  from  acromegaly, by  the  absence  of  enlargement  of 
the  hands,  feet  and  jaws,  while,  far  from  increasing  in  stature,  the  patient 
lecidedly  shrunken  and  bowed.  No  treatment  lor  this  disease  is 
known. 

(g)  Leontiasis  Ossea.     This  rare  condition  can  hardly  be  regarded  as  a 

bone  hut  a  local  hyperostosis  (whether  inflammatory  or 


Fig.  L51. 


Osteitis  deformans.     Tibia  and 
m  fibula  (X-ray). 


INFECTIONS  OF  BONE  361 

neoplastic  is  uncertain)  of  the  jaws  and  facial  bones,  which  will  be  discussed 
in  the  section  referring  to  those  parts. 

(I)  Inflammatory  and  Parasitic  Affections  of  Bone.  These  fall 
into  three  groups  :  (a)  Traumatic  affections  ;  (b)  microbic  and  protozoal 
infections,  which  are  the  most  common  and  important  of  all  diseases  of 
bones  ;   (c)  hydatid  disease. 

Inflammatory  diseases  of  joints  are  closely  allied  to  those  of  bones,  since 
infections,  if  severe  or  of  long  duration,  readily  spread  from  bones  to  joints 
or  vice  versa,  and  in  any  case  usually  take  origin  in  bones  close  to  joints. 
The  ends  of  bones  form  a  very  important  part  in  the  structure  of  joints, 
and  in  general  a  process  starting  in  a  bone  on  the  joint  side  of  an  epiphyseal 
line  will  be  regarded  as  an  affection  of  the  corresponding  joint,  while  if 
starting  on  the  diaphyseal  side  of  the  epiphyseal  line  it  will  be  classed  as  a 
bone-infection  proper.  The  importance  of  the  epiphyseal  line  of  cartilage 
as  an  agent  for  keeping  infection  to  one  part  of  the  osseo-articular  system 
is  thus  clear.  Diseases  of  bones  and  joints,  though  by  no  means  confined 
to  the  growing  bone,  are  yet  of  more  frequent  occurrence  and  greater 
importance  in  young  persons. 

(a)  Traumatic  Inflammations  of  Bone.  These  have  already  been  discussed 
under  Injuries  of  Bones. 

(6)  Infective  Diseases  of  Bone.  These  affections  may  be  due  to  various 
pyogenic  cocci,  especially  staphylococcus  aureus  and  pneumococci,  less 
often  to  streptococci.  The  enteric  bacillus  accounts  for  a  few  cases,  while 
the  spirochete  of  syphilis  and  the  tubercle  bacillus  are  responsible  for  a 
large  number  of  the  more  chronic  infections,  and  the  organisms  of  leprosy, 
glanders  and  actinomycosis  are  also  found  in  lesions  of  bone. 

There  is  rather  a  superfluity  of  nomenclature  and  confusion  of  causes 
in  describing  infections  of  bone,  according  to  the  part  most  affected  and  the 
manner  of  spread  of  the  disease.  Thus  the  term  periostitis  is  applied 
where  the  periosteum  is  the  part  chiefly  involved,  osteomyelitis  where 
the  dense  shaft  and  medulla  are  infected,  &c.  In  all  cases  an  osteitis 
or  inflammation  of  the  bone  is  present  to  a  greater  or  less  degree. 
On  the  whole,  a  division  according  to  the  type  of  infective  organism 
and  the  site  of  the  initial  lesion  seems  the  most  satisfactory  method  of 
classification. 

(I)  Infections  due  to  Pyogenic  Cocci.  In  nearly  all  cases  the  staphylo- 
coccus aureus  is  the  organism  responsible,  though  the  pneumococcus  and 
less  often  the  streptococcus  produce  similar  lesions,  and  the  sites  of  infection 
are  :  (a)  any  point  along  the  shaft  of  the  bone,  the  infection  usually  tending 
to  become  localized  ;  (6)  infections  starting  in  the  cancellous  tissue  of  the 
diaphysis  just  under  the  epiphyseal  cartilage,  and  often  spreading  widely 
(juxta-epiphyseal). 

(a)  Infections  originating  at  any  point  of  the  shaft  may  be  divided 
into  :  (1)  those  where  the  inflammation  is  mostly  superficial  (periostitis)  ; 
(2)  those  where  the  whole  thickness  of  bone  is  involved  (localized  osteo- 
myelitis).    The  localization  in  these  conditions  must  not  be  taken  too 


\  TEXTBOOK  OF  SURGERY 

literally,  for  in  unfavourable  cases  the  infection  may  spread  widely  and 
involve  most  of  the  bone,  though  this  is  not  usual. 

(1)  Local  Periostitis.  This  usually  follows  injury,  whether  with  a  wound 
leading  down  to  the  hone  or  from  infection  of  the  damaged  periosteum  with 
pyogenic  organisms,  from  some  local  wound,  or  via  the  blood-stream,  and 
may  result,  apart  from  injury,  in  the  course  of  general  blood  infections, 
as  pyaemia  (especially  if  the  original  focus  of  infection  was  in  bone),  enteric 
fever,  and  the  exanthemata. 

Anatomy.  The  periosteum  becomes  congested  and  thickened;  there  is 
exudation  of  lymph  and  activity  of  the  osteoblasts.  In  most  instances  of 
pyogenic  infection  the  vessels  of  the  periosteum  and  neighbouring  bone 
thrombose,  the  exudation  breaks  down  into  pus,  and  the  bone  from  which 
the  periosteum  is  stripped  dies  superficially,  leading  to  a  formation  of  a  thin 
sequestrum,  which  maybe  absorbed  if  small,  or  is  separated  later  by  granu- 
lation tissue  and  discharged  from  the  abscess.  In  some  instances  the 
blood-supply  is  restored  to  the  bone  although  stripped  of  periosteum,  and 
the  bare  area  heals  in  again  without  any  discernible  necrosis  taking  place. 
In  still  less  severe  cases  there  may  be  no  suppuration,  but  as  a  result  of 
the  increased  activity  of  the  deeper  layers  of  the  periosteum  and  bone  there 
is  a  deposit  of  new  bone  and  a  node  of  bone  forms  at  the  site  of  inflammation, 
just  as  happens  in  traumatic  and  syphilitic  affections.  The  destruction 
of  the  underlying  bone  depends  very  largely  on  the  stripping  of  periosteum 
by  the  exuded  lymph  and  pus  ;  hence  the  importance  of  early  operation  and 
evacuation  of  such  exudate. 

Signs.  Pain  in  the  portion  of  the  bone  affected,  with  a  tender  swelling 
on  the  bone  not  separable  from  it.  while  if  affecting  a  superficial  part,  e.g. 
the  tibia  or  skull,  redness  and  oedema  of  the  skin  and,  later,  fluctuation 
will  be  noted  :  if  a  wound  be  present  this  appears  unhealthy,  swollen,  not 
tending  to  heal,  and  with  a  purulent  discharge,  while  bare  bone  may  be 
detected  by  sight  or  the  probe  in  the  depths  of  the  wound.  Of  general 
symptoms,  fever  is  usual,  often  of  moderate  degree,  and  rigors  are  uncommon. 

Treatment.  As  long  as  it  is  uncertain  that  suppuration  has  occurred  or 
probable  that  this  change  has  not  supervened,  rest,  elevation  of  the  part, 
and  the  application  of  cooling  lotions  are  permissible.  But  where  there  is 
redness  and  oedema  of  the  skin,  or  fluctuation  and  bogginess  of  the  part,  or 
where  high  fever  or  other  severe  general  signs  are  present,  no  time  should 
be  lost  but  the  part  explored  by  free  incision,  the  subperiosteal  abscess 
we]]  opened  ;lnd  drained  for  a  few  days,  till  the  discharge  becomes  serous. 
In  most  instances  there  is  no  need  to  chisel  into  the  bone,  but  if  severe 
general  signs — fever,  delirium,  rigors — are  present  at  the  outset,  or  if  the 
course  is  not  satisfactory  after  draining  the  subperiosteal  abscess,  the  bone 
should  be  explored  freely  with  the  chisel,  making  a  wide  opening  into  the 
medulla,  cutting  away  dead  and  inflamed  bone,  and  establishing  free 
drainage. 

Superficial  sequestra  usually  separate  in  about  two  months,  and  if  the 
general  condition  of  the  patient  be  good  there  is  no  need  to  remove  dead 


JUXTA-EPIPHYSEAL  INFECTIONS.    ACUTE  DIAPHYSITIS    363 

bone  till  it  becomes  loose.     After  removing  a  sequestrum  or  cutting  away 
dead  or  inflamed  bone,  healing  by  granulation  is  usually  rapid. 

(2)  Acute  localised  osteomyelitis  is  usually  the  result  of  infected  com- 
pound fractures  or  of  amputations  for  infective  conditions  where  asepsis 
has  not  been  attained — very  rarely,  in  these  days,  as  the  result  of  osteotomies 
or  other  operations  on  bones.  This  affection  may  also  follow  on  acute 
localized  periostitis,  of  which  it  is  indeed  a  glorified  example,  the  infection 
having  spread  into  the  depths  of  the  bone  and  medulla,  Occasionally  pysemic 
abscesses,  usually  secondary  to  bone  infection,  may  lead  to  this  condition. 

Anatomy.  This  is  similar  to  the  condition  previously  described  as  far 
as  the  periosteum  is  concerned,  but  in  addition  there  are  congestion  and 
exudation  into  the  dense  bone  and  medulla,  so  that  from  the  resulting 
thrombosis  a  considerable  area  of  bone  dies,  forming  a  sequestrum  which  in  the 
case  of  an  amputation  through  the  shaft  of  a  long  bone  consists  of  a  segment 
of  the  lower  end  of  the  bone  in  the  form  of  a  ring  or  tube  of  varying  length. 

Signs.  These  resemble  those  of  the  milder  periosteal  form  but  are  of 
greater  severity-  The  wound  becomes  sloughy  and  swollen  ;  the  skin  around 
cedematous,  purple-red  in  colour  ;  thin  pus  exudes  from  the  wound  ;  high 
fever,  delirium,  and  rigors  are  .not  uncommon  and  the  general  depression 
is  greater  ;  while  from  the  involvement  of  larger  venous  sinuses  in  the 
bone  and  medulla  the  prospect  of  infective  embolism  leading  to  pyaemia 
is  much  greater — though  if  freely  opened  the  dead  bone  is  as  a  rule  gradually 
separated  and  discharged  as  a  sequestrum. 

Treatment  consists  in  opening  the  wound,  removing  inflamed  and  dead 
bone  and  infected  medulla,  and  establishing  free  drainage.  Usually  this 
will  cause  the  inflammation  to  quiet  down  and  later  sequestra  may  need 
removal,  but  if  grave  constitutional  disturbance  persists  amputation  at  a 
higher  point  of  the  limb  will  be  needed. 

(b)  Infections  starting  in  the  diaphysis  close  to  the  epiphyseal  line. 

Juxta-epiphyseal  Infections.  These  affections  forma  great  natural 
group  of  bone  diseases,  and  from  the  frequency  of  incidence  and  fulminating 
fatality  in  many  instances  are  the  most  important  and  tragic  of  all  classes 
of  bone  disease.  These  affections  are  also  known  as  acute  spreading  osteo- 
myelitis, acute  diaphysitis,  acute  epiphysitis,  panosteitis,  &c. 

The  underlying  cause  is  an  infection,  usually  with  staphylococci,  of  the 
newly  formed  bone  of  the  juxta-epiphyseal  part  of  the  diaphysis.  The 
reason  for  the  frequency  of  infection  of  this  region  is  uncertain.  It  has  been 
supposed  to  be  due  to  the  excessive  vascularity  of  this  part  of  the  bone, 
but  modern  pathology  hardly  warrants  such  a  view.  The  newly  formed 
bone  may,  however,  be  delicate,  and  it  is  fully  recognized  that  the  junction 
of  the  newly  formed  bone  of  the  diaphysis  with  the  epiphyseal  cartilage  is 
a  weak  point,  It  is  here  that  in  separation  of  an  epiphysis  solution  of 
continuity  takes  place,  and  probably  in  cases  where  less  severe  violence  has 
been  exerted  there  is  some  disruption  of  the  weak  part  of  the  bone  and 
effusion  of  blood  without  any  displacement  that  can  be  detected  (juxta- 
epiphyseal  strain  of  Oilier).     This  effusion  and  the  damaged  new  bone  form 


A  TEXTBOOK  OK  SURGERY 


a  nidus  suitable  for  the  Infective  organisms  fco  take  coot  and  flourish,  the 
infection  being  of  circulating  cocci,  blood-borne  to  the  damaged  part.  Against 
this  view  it  is  curious  how  seldom  Buppural  ion  takes  place  in  cases  of  definite 
separation  of  epiphyses;  moreover,  in  many  cases  no  history  of  injury  is 
obtainable  :  still  children  are  constantly  falling  about,  and  we  know  with 
what  Blight  violence  separation  of  some  epiphyses  can  be  produced,  e.g. 


Fig.   152.     Results  of  juxta-epiphyseal  infections  (diaphysitis).     1,  Periostitis  and 

subperiosteal  abscess.     2,  Osteomyelitis.     3,  Localized  chronic   abscess   (Brodie's 

abscess).     4,   Periostitis   ami    oesteomyelitis.     5,  Arthritis   (where  the   epiphyseal 

line  is  inside  the  joint ,  , .rj.  the  hip),     (i,  Epiphysitis  and  arthritis. 

the  upper  epiphysis  of  the  femur.     The  results  of   such  juxta-epiphyseal 
infection  varies  with  the  relation  of  the  virulence  of  the  infection  to  the 
Hue  of  the  patient  and  the  position  of  the  lesion  in  the  epiphyseal  line, 
i.e.  whether  situated  at  the  outer  part  of  this  or  nearer  the  centre. 

Tims  if  the  focus  of  infection  be  near  the  edge  of  the  epiphyseal  cartilage 
it  will  soon  spread  to  the  periosteum  and  the  effusion  will  strip  the  latter, 
forming  a  subperiosteal  abscess,  the  condition  then  being  known  as  acute 
infective  periostitis.  If  the  lesion  is  nearer  the  centre  of  the  epiphyseal 
cartilage  the  spread  will  more  readily  be  into  the  cancellous  bone  of  the 
diaphysis  and  will  spread  through  this  into  the  medulla,  which  may  be 
infected  before  the  periosteum  is  reached  or  about  the  same  time  ;   such  a 


JUXTA-EPIPHYSEAL  INFECTIONS 


J65 


condition  is  known  as  acute  diaphysitis  or  acute  spreading  osteomyelitis. 
If  the  virulence  of  the  infection  is  relatively  mild  and  is  situated  in  the 
central  part  of  the  epiphyseal  line  the  result  is  a  slow  destruction  of  the 
cancellous  bone  and  sclerosis  of  the  bone  surrounding  this  area,  causing 
the  formation  of  a  cold  or  chronic  abscess,  often  known  as  Brodie's 
abscess.  In  practice  interme- 
diate conditions  will  be  found 
between  these  extreme  types. 
The  escape  of  pus  from  the 
region  of  the  diaphyseal  line 
below  the  periosteum  has  a 
safety-valve  action,  relieving 
tension,  and  the  most  severe 
cases  are  those  where  the  in- 
fection is  confined  to  the  can- 
cellous bone  and  medulla  for 
some  time. 

(1)  Acute  Suppurative 
Periostitis  of  Juxta-epi- 
physeal  Origin.  In  these 
cases  the  pus  formed  at  the 
seat  of  infection  travels  along 
the  path  of  least  resistance 
and  strips  the  periosteum, 
leaving  the  central  part  of 
the  epiphyseal  line  and  the 
cancellous  bone  intact.  The 
bone  under  the  stripped  peri- 
osteum dies  to  a  varying  ex- 
tent, but  if  the  pus  is  let  out 
by  timely  incision  the  amount 
which  succumbs  may  be  slight 
and  of  superficial  position, 
and  may  be  absorbed  by  the 
granulation  tissue  without 
separation  of  sequestra.  More 
often  a  considerable  part  of 
the  bone  dies  and  the  infec- 
tion extends  into  the  me- 
dulla, the  dead  part  being  later  cast  off  as  a  sequestrum,  and  the 
condition  being  closely  allied  to  the  next  variety. 

(2)  Acute  Diaphysitis  of  Juxta-epiphyseal  Origin.  (We  give  this 
name  as  best  expressing  the  nature  of  the  disease,  other  synonyms  being 
acute  infective  osteomyelitis,  acute  necrosis,  acute  periostitis,  acute  pan- 
osteitis, &c.) 

This  is  a  very  grave  and  often  fatal  disease.     The  infective  focus  being 


Fig.  153.  Skiagram  of  subacute  periostitis  of  the 
lower  end  of  the  femur.  New  formation  of  perios- 
teal bone  is  seen  in  the  upper  part,  but  lower  where 
the  process  is  more  acute  no  such  formation  has 
occurred. 


A  TEXTBOOK  OF  SURGERY 

at  a  distance  from  the  periosteum,  the  spread  is  into  the  cancellous  bone 
at  the  fml  of  the  diaphysis  and  passes  to  the  medulla.  The  vessels  throm- 
and  death  of  a  large  portion  of  the  diaphysis  rapidly  takes  place.  In 
a  large  number  of  instances,  however,  the  infection  spreads  to  the  periphery 
as  well  and  the  exudation  strips  the  periosteum,  thus  increasing  the  damage 
to  the  vitality  of  the  shaft  and  the  amount  which  dies.  The  marrow  of  the 
cancellous  part  becomes  yellowish-white  and  soon  breaks  down  into  pus, 
while  the  blood  sinuses  of  the  cancellous  bone  and  medulla  are  soon  filled 
with  clot.  The  dense  bone,  bared  of  periosteum,  is  found  to  be  white  and 
does  not  bleed  when  cut  into.  The  process  varies  greatly  in  its  severity 
and  tendency  to  form  metastatic  deposits  by  embolism  from  the  thrombosed 
sinuses  of  the  bone  and  medulla.  In  the  ultra-acute  or  fulminating  variety 
infective  pericarditis,  broncho-pneumonia,  and  pyaemic  abscesses  in  other 
joints  and  bones  form  rapidly,  while  if  the  infection  be  of  more  moderate 
degree  the  whole  diaphysis  may  be  bare  and  dead,  lying  in  a  bag  of  pus 
contained  by  the  periosteum,  the  patient  being  but  moderately  ill. 

Thus  on  the  one  hand  we  may  find  a  patient  dying  within  forty-eight 
hours  from  the  onset  of  the  disease  with  a  tiny  focus  of  staphylococcal  pus 
in  the  lower  epiphyseal  line  of  the  femur,  but  with  severe  pericarditis, 
broncho-pneumonia,  and  profound  toxaemia  ;  on  the  other  a  patient  is 
watched  for  six  weeks  as  rheumatism,  and  when  seen  the  thigh  is  one  bag 
of  pus  in  which  the  bare  femur  is  lying — the  patient  not  being  severely  ill. 

(3)  Acute  Infective  Epiphysitis  (true  epiphysitis).  This  is  uncommon, 
the  infection  spreading  through  the  protective  line  of  cartilage  into  the 
cancellous  bone  of  the  epiphysis.  The  involvement  of  joints  from  infections 
of  juxta-epiphyseal  origin  are  usually  in  places  where  the  epiphyseal  line 
is  inside  the  joint,  as  in  the  case  of  the  hip-joint. 

Signs  of  Acute  Suppurative  Periostitis  and  Acute  Diaphysitis. 
From  the  clinical  standpoint  these  may  be  considered  together,  since  it  is 
only  from  the  course  of  the  disease  that  we  can  be  sure  to  what  extent  the 
bone  is  involved  ;  further,  we  would  divide  these  infections  into  (a)  the 
fulminating,  (b)  the  acute,  (c)  the  subacute. 

(a)  Fulminating  Diaphysitis.  There  is  a  sudden  onset  of  pain  in  the 
proximity  of  the  joint,  but  a  more  careful  investigation  will  show  that  the 
joint  is  not  the  seat  of  pain  but  the  bone  close  by.  There  is  high 
fever,  104°  to  105°,  often  with  rigors,  pointing  to  metastatic  infections,  and 
frequently  delirium.  The  patient  has  the  flushed  face,  dirty  tongue  of 
septic  fever.  The  local  signs  are  often  slight :  tenderness  over  the  end  of 
a  bone  may  be  all  that  can  be  discovered,  and  this  is  caused  by  pressure  on 
the  bone  and  not  by  gentle  movement  of  the  corresponding  joint  (which 
distinguishes  the  condition  from  an  acute  arthritis)  ;  but  if  delirium  is. 
marked  it  may  be  very  difficult  to  decide  where  the  really  tender  point  is 
situated.  Later  the  seat  of  infection  is  decided  by  the  appearance  of  a 
swellitii  over  the  end  of  the  hone,  rapidly  increasing  in  size  and  becoming 
brawny,  red,  and  fluctuating.  In  the  ultra-acute  types,  however,  death 
may  occui  before  local  signs  other'than  tenderness  are  marked. 


ACUTE  DIAPHYSITIS  367 

(b)  Acute  Diaphysitis  and  Periostitis.  The  onset  is  similar  to  that  in  the 
previous  condition,  but  the  fever  is  less  high  and  the  constitutional  depression 
less  severe.  There  will  be  time  for  a  boggy  swelling  to  appear  at  the 
extremity  of  the  -affected  bone,  the  neighbouring  joint  being  unaffected 
unless  the  infection  has  spread  to  this  secondarily.  Delirium  is  often  a 
marked  feature  of  these  cases  also.  Secondary  infections  are  found  in  the 
pericardium,  lungs  and  pleura,  and  often  in  joints  or  other  epiphyseal 
lines,  giving  the  classical  picture  of  pyaemia. 

(c)  In  the  subacute  varieties  the  general  condition  is  far  less  grave,  the 
onset  is  more  gradual,  the  fever  lower — often  not  above  101° — while  a 
swelling  gradually  appears  at  the  end  of  a  bone  and  slowly  forms  along 
the  shaft.  If  the  bone  is  superficial  the  swelling  is  red  and  boggy,  but  if 
deep,  fluctuation  alone  may  be  noted  for  some  time. 

As  the  infection  is  essentially  one  of  growing  bones  and  attacking  the 
epiphyseal  end  of  these,  it  will  rarely  be  found  over  twenty-two  and  is  not 
common  before  six  years  of  age. 

Diagnosis.  Too  many  lives  are  lost  by  confusing  this  severe  disease 
in  its  earlier  stages  with  rheumatism  ;  nor  is  the  diagnosis  easy  in  some  in- 
stances, but  early  diagnosis  and  early  and  drastic  operative  treatment  is  the 
only  hope  for  the  more  severe  cases.  The  very  high  fever,  the  occurrence 
of  rigors,  above  all  the  irritable  delirium,  are  seldom  found  in  rheumatism. 
The  absence  of  multiple  affection  of  joints  (unless  pyaemia  is  well  advanced) 
and  the  fact  that  pain  and  tenderness  are  not  really  in  the  joints  will  decide 
the  matter.  There  must  be  no  waiting  till  local  swelling  makes  matters 
clear.  Any  child  found  with  high  fever,  delirium,  and  a  tender  spot  over 
the  end  of  a  bone  should  have  that  bone  explored  at  once  ;  nor  should  the 
surgeon  be  content  with  examining  the  outside  of  the  bone  if  this  appear 
normal ;  he  should  chisel  into  the  medulla  at  the  tender  spot,  and  will 
almost  certainly  find  infection  there,  for  the  outside  of  the  bone  may  be 
normal  when  the  cancellous  tissue  and  medulla  are  severely  infected. 

In  the  later  stages  of  the  milder  infections  diagnosis  is  less  difficult,  but 
it  should  be  remembered  that  multiple  affection  of  joints  may  be  pyaemic 
as  well  as  rheumatic,  and  pericarditis  is  common  to  both  diseases  :  the 
earthy  colour  of  the  skin,  the  irregular  fever  and  sweats,  leucocytosis,  and 
the  scattered  abscesses  in  subcutaneous  tissues  or  other  bones  and  joints, 
found  in  the  graver  condition  will  as  a  rule  suffice  to  differentiate. 

The  more  acute  types  resemble  other  severe  intoxications,  such  as 
enteric  fever ;  but  the  slower  onset  of  the  latter,  the  lower  fever,  absence 
of  rigors,  presencs  of  rash  and  enlarged  spleen  will  help  in  diagnosis. 

Infantile  scurvy  may  be  taken  for  periostitis,  but  the  age  being  under 
one  year  renders  periostitis  most  unlikely  ;  the  less  severe  constitutional 
disturbance  and  the  method  of  feeding  wTill  soon  throw  light  on  the  matter. 

Prognosis.  This  is  always  grave  in  the  more  acute  forms.  Many  cases 
die  in  the  first  few  days  of  acute  toxaemia  with  pericarditis  and  broncho- 
pneumonia ;  or,  later,  of  pyaemia,  wasting  from  prolonged  suppuration 
and  lardaceous  disease.     When  recovery  takes  place  and  sequestra  separate 


A  TEXTBOOK  OF  SURGERY 

healing  is  usually  good,  new  bono  being  formed  in  abundance  from  the 
stripped  periosteum  to  supply  the  place  of  the  lost  diaphysis;  but  the 
periosteum  may  be  bo  damaged  that  no  new  bone  is  formed  and  the  limb 

will  become  Hail-like  and  useless  unless  successful  bone-grafting  be  carried 
out.  of  which  McEwen  lias  produced  such  famous  examples.  The  general 
mortality  is  •">-"»  per  cent.  (Kennedy). 

The  tibia  is  most  commonly  affected,  accounting  for  nearly  half  the  cases  ; 
the  upper  end  is  affected  more  commonly  than  the  lower.  The  femur  is 
affected  in  about  one-quarter  of  the  remaining  cases,  the  lower  end  being 
affected  more  often  than  the  upper.  The  upper  end  of  the  humerus  is  the 
part  next  most  frequently  affected  and  the  other  bones  but  rarely  (Kennedy). 

Treatrm  nt.  Operation  should  be  prompt.  The  bone  is  exposed  by 
incision  over  the  whole  length  of  the  swelling  if  one  be  present,  or  to  freely 
expose  tin'  end  of  the  bone,  where  tenderness  is  the  only  localizing  sign. 
(are  should  be  taken  to  avoid  the  course  of  large  vessels.  Thus  the  lower 
end  of  the  femur  should  be  exposed  on  its  outer  side,  never  from  the  popliteal 
space,  since  if  this  is  done  secondary  haemorrhage  is  likely  to  result  from  the 
combination  of  pressure  of  the  drainage-tube  and  infection,  causing  ulcera- 
tion of  the  vessel.  It  the  periosteum  is  found  to  be  stripped  by  effusion  of 
pus,  it  should  be  slit  up  along  the  stripped  area.  The  next  question  is 
whether  to  open  the  bone.  As  it  is  impossible  to  be  certain  that  the  can- 
cellous tissue  and  medulla  are  not  affected,  it  is  safest  to  do  this  in  all  cases, 
but  if  on  reaching  the  deeper  parts  the  bone  and  medulla  are  found  to 
be  bleeding  freely  and  there  are  no  signs  of  suppuration,  the  operation  should 
be  stopped  at  this  point  and  the  wound  in  the  bone  packed  with  gauze  for 
a  few  davs  and  the  superficial  sequestrum  allowed  to  separate  or  be  absorbed. 
Where  no  lesion  is  fomid  on  the  surface  of  the  bone  the  latter  should  be 
freely  opened  and  the  underlying  cancellous  tissue  and  medulla  carefully 
explored  and  all  necrotic  matter,  dead  bone,  thrombosed  medulla  and 
cancellous  tissue  removed,  which  may  imply  cutting  away  a  large  mass  of 
bone.  Where  the  periosteum  has  been  stripped  and  the  medulla  is  infected 
as  well,  a  great  gutter  should  be  cut  into  the  medullary  cavity,  removing 
medulla  and  cancellous  bone  till  healthy  bone  and  medulla  are  reached  : 
the  cavity  is  swabbed  out  with  pure  carbolic  and  lightly  packed  wdth  gauze, 
the  superficial  wound  being  left  for  the  most  part  open.  In  favourable 
instances  the  remains  of  the  dead  bone  will  separate  off  in  about  three 
months  and  become  loose,  when  it  can  be  extracted  from  its  sheath  of  newdy 
formed  periosteal  bone  by  enlarging  the  drainage-holes  or  splitting  the 
sheath  of  new  bone,  the  operation  being  known  as  sequestrotomi/. 

Not  all  cases,  however,  have  such  a  favourable  termination,  even  after 
the  bone  is  freely  laid  open — fever  may  persist,  repeated  rigors  occur,  and 
pyaemic  abscesses  develop  :    in  such  cases  there  are  two  alternatives,  either 

(1)  to  remove  the  whole  diaphysis,  or  at  any  rate  the  end  affected,  or 

(2)  to  amputate  the  limb.  It  is  reasonable  to  commence  with  the  first  and 
less  severe  measure,  though  if  the  signs  of  general  infection  are  very  severe 
immediate  amputation  may  be  the  correct  treatment. 


DIAPHYSECTOMY.    SEQUESTEOTOMY  369 

Diaphysectomy.  Removal  of  the  diaphysis  (Stiles)  is  indicated  when 
after  free  opening  of  the  bone  infection  still  persists,  the  condition  of  the 
patient  becoming  steadily  more  grave  :  this  operation  may  also  be  performed 
at  the  outset  of  the  disease  if  the  general  condition  is  grave  or  the  area 
of  bone  denuded  of  periosteum  is  large,  or,  later,  when  the  diaphysis  is  con- 
verted into  a  sequestrum  lying  in  a  bag  of  pus.  In  most  cases  the  periosteum 
can  be  readily  separated  from  the  diaphysis  where  still  adherent  :  at  the 
epiphyseal  line  separation  is  usually  easy,  but  the  attachments  of  muscles 
may  need  some  force  to  remove  ;  a  long  incision  renders  the  proceeding 
easier.  When,  after  the  bone  has  been  freely  opened,  the  signs  of  toxaemia 
do  not  abate  but  remain  or  become  more  severe,  diaphysectomy  should  be 
performed  within  forty- eight  hours  of  the  previous  operation. 

Amputation.  There  can  be  no  doubt  that  the  most  severe  cases  are 
only  to  be  saved  by  immediate  amputation,  but  the  surgeon  is  faced  with 
a  very  difficult  question,  since  the  prognosis  is  uncertain,  and  if  after  ampu- 
tation is  performed  the  patient  recovers  there  will  always  be  some  feeling 
that  recovery  might  have  taken  place  after  some  less  mutilating  measure, 
such  as  diaphysectomy.  Amputation  is  indicated  as  a  secondary  measure 
when,  after  removal  of  the  diaphysis,  the  patient  continues  to  go  down- 
hill, or  where  severe  secondary  haemorrhage  takes  place  which  is  not  checked 
by  ligature  of  the  main  artery  of  the  limb. 

Sequestrotomy.  After  the  bone  has  been  opened  and  drained  and 
the  acute  symptoms  have  passed  off,  the  periosteum,  which  has  been  stripped 
by  the  exudation  of  pus,  begins  to  form  new  bone  on  its  inner  surface,  and 
this  sheath  of  new  bone  surrounds  the  dead  diaphysis  or  sequestrum,  being 
known  as  the  Involucrum  ;  the  apertures  in  this  through  which  pus  constantly 
drains  off  are  known  as  Clcacce.  The  sequestrum  should  not  be  removed 
from  the  involucrum  for  at  least  two  months  in  cases  where  the  patient  is 
no  longer  suffering  from  signs  of  intoxication.  This  will  allow  time  for 
the  involucrum  to  become  sufficiently  strong  not  to  collapse  when  the 
sequestrum,  which  supports  its  inner  surface,  is  removed.  In  cases  where 
a  sequestrum  has  to  be  removed  earlier  a  support  should  be  placed  inside 
the  periosteum  to  prevent  such  a  crumpling  up  of  the  latter.  A  vulcanite 
rod  serves  the  purpose  very  well  and  can  be  removed  when  the  new  bone 
of  the  involucrum  is  becoming  firm. 

The  power  of  regeneration  of  bone  from  the  periosteimi  varies  with 
the  severity  of  infection  and  also  with  the  bone  affected  Regeneration  is 
very  good  in  the  tibia,  and  in  the  clavicle  even  better,  in  which  a  well-shaped 
new  clavicle  may  be  developed  from  periosteum  within  six  weeks  of  removal 
of  a  necrotic  diaphysis.  At  the  lower  end  of  the  femur  the  prospect  is  less 
good ;  in  some  cases  there  may  be  no  production  of  new  bone  over  a  con- 
siderable extent,  and  in  such  cases  bone-grafting  is  needed 

(I)  Chronic  Pyogenic  Juxta-epiphyseal  Abscesses  (Brodie's  Abscess). 

When  the  infection  of  the  epiphyseal  line  is  relatively  mild  the  process  may 

remain  circumscribed,  the  cancellous  bone  is  slowly  destroyed,  and  a  cold 

abscess  forms  in  the  interior  of  the  end  of  the  diaphysis,  round  which  there 

i  24 


\  TEXTBOOK  OF  SURGERY 

is  considerable  sclerosis,   the    bone   becoming  wider  and    also  denser  in 
structure. 

■  is  gradual  :  pain  is  noted  at  the  end  of  a  bone,  especially 
on  movement  on  placing  weight  on  the  limb  and  at  night.  Deep 
tenderness  of  the  end  of  the  bone  will  be  found  on  palpation.  Later  there 
will  be  found  swelling  of  the  tissues  over  the  end  of  the  bone,  which  may 
become  oedematous  and  red.  though  these  signs  are  seldom  found  for  several 
weeks  or  months.  Still  later  the  abscess  may  burst  on  the  surface,  leaving 
a  fistulous  tract  leading  into  the  centre  of  the  bone.  Less  often  the 
abscess  may  become  absorbed,  the  bone  being  left  thickened  and  sclerosed. 

Diagnosis.  This  has  to  be  made  from  disease  of  the  neighbouring  joint, 
which  will  be  easy  unless  the  abscess  has  burst  into  the  latter,  since  other- 
wise the  joint  remains  unaffected  in  its  movements  and  there  is  no  thickening 
of  the  synovial  membrane.  More  important  is  the  diagnosis  from  new 
growths  of  the  ends  of  bones.  From  innocent  tumours  (exostoses)  the  pain 
and  cedema  and  more  regular  and  general  swelling  will  distinguish,  for  in 
the  new  growths  of  innocent  type  the  swelling  is  localized  to  one  aspect 
of  the  bone. 

From  new  growths  of  the  periosteum  (usually  sarcomas)  the  more  regular 
swelling  involving  the  whole  circumference  of  the  bone  in  the  case  of 
abscess,  and  the  fact  that  it  rises  more  gradually  from  the  neighbouring 
shaft,  will  discriminate  in  most  instances.  From  central  new  growths 
(myeloid)  the  diagnosis  in  the  early  stages  will  not  be  easy,  as  in  both  the 
swelling  is  slight.  In  the  later  stages  the  fact  that  a  new  growth  rises  more 
sharply  and  definitely  from  the  surrounding  bone  while  the  inflammatory 
condition  is  more  fusiform  in  shape,  and  the  pain,  cedema,  and  fluctuation 
of  the  last  condition  will  serve  to  distinguish.  X-rays  are  most  useful  in 
the  diagnosis  of  these  cases,  especially  in  the  early  stages.  In  the  case  of 
abscess  the  sclerosis  round  the  focus  of  infection  renders  the  shadow  of  the 
bone  so  dense  that  the  hollow  caused  by  the  abscess  may  be  hard  to  see 
unless  very  careful  inspection  be  made,  whereas  in  the  case  of  myeloid 
growths  the  bone  is  rarefied  by  the  tumour,  with  no  corresponding  sclerosis 
around,  and  hence  the  loss  of  substance  of  the  bone  shows  very  clearly  in  a 
radiograph.  In  inflammatory  conditions  where  there  is  but  little  sclerosis, 
as  in  tuberculous  abscesses,  the  resemblance  to  myeloma  is  much  greater. 
The  radiograph  will  also  readily  distinguish  between  central  abscess,  growths 
of  the  periosteum  and  exostoses. 

From  chronic  periostitis  and  osteitis,  such  as  is  met  with  in  tertiary 
and  congenital  syphilis,  the  diagnosis  is  made  by  the  less  wide  involvement 
of  the  diaphysis,  which  in  the  latter  conditions  may  be  involved  to  half 
or  more  of  its  length) ;  the  greater  chronicity  of  the  syphilitic  inflammations, 
and  the  absence  of  oedema  and  swelling  of  surrounding  tissues  over  the 
osseous  lesion,  as  well  as  the  absence  of  rarefaction  of  the  centre  of  the  bone 
as  seen  in  radiographs,  will  also  help  to  distinguish. 

'"<•  ft.    The  abscess  should  be  explored — opening  the  bone  with 
•  or  chisel,  removing  pus  and  granulation  tissue,  and  cutting  away  the 


TUBERCULOSIS  OF  BONE  371 

carious  wall  of  the  abscess.  Then  the  cavity  may  be  (1)  packed  with  gauze 
and  allowed  to  heal  from  the  bottom  ;  a  better  plan  (2)  is  to  cut  away  the 
outer  wall  of  the  abscess  very  freely  and  push  the  flap  of  skin  and  soft  tissues 
down  into  the  cavity  thus  left,  and  so  obliterate  it,  the  flap  becoming 
adherent  with  the  deeper  surface  of  the  cavity  in  the  bone.  The  later 
growth  of  the  bone  will  gradually  push  up  the  skin-flap  till  it  assumes 
something  like  its  normal  position.  (3)  The  best  plan  of  all.  when  successful, 
is  by  the  process  of  "  bone-stopping,"  which  is  analogous  to  that  employed 
by  dentists  in  stopping  teeth.  After  clearing  out  the  abscess-cavity,  it  is 
dried  and  purified  with  pure  carbolic,  again  dried  and  filled  with  sterilized 
mutton-fat.  which  is  run  in  molten  into  the  cavity.  Hard  paraffin-wax 
may  be  used  for  this  purpose  (the  original  plan  was  to  use  a  mixture  of 
spermaceti,  paraffin,  and  iodoform).  The  "  stopping."  after  being  ran  in, 
is  covered  with  the  periosteum  and  the  skin-flap  sutured  in  place :  the 
stopping  is  gradually  replaced  by  new  bone,  which  fills  up  the  abscess- 
cavity.  There  is  always  a  chance  that  the  aseptic  technique  may  fail  in 
these  cases  and  the  wax  be  extruded  by  the  resulting  suppuration,  in  which 
case  the  cavity  will  need  to  be  packed  with  gauze  or  the  second  method 
employed. 

(5)  Pyogenic  Infections  of  the  Short  Bones.  Of  the  same  nature 
as  the  juxta-epiphyseal  lesions  are  infections  of  the  cancellous  tissue  of 
the  short  bones,  of  which  the  os  calcis  and  astragalus  are  examples.  In 
the  former  instance  the  infection  may  start  in  the  neighbourhood  of  the 
posterior  epiphysis.  The  signs  and  treatment  are  similar  to  the  above- 
described  lesions  of  long  bones,  but  owing  to  the  greater  proximity  of  joints 
these  are  more  likely  to  be  involved. 

(II)  Tuberculous  Infections  of  Bone.  Infection  with  the  tubercle  bacillus 
produces  subacute  and  chronic  rarefying  osteitis  of  bones  ;  seldom  does  any 
sclerosis  follow,  and  necrosis  with  formation  of  sequestra  is  quite  uncommon. 

The  infection  usually  starts  in  cancellous  bone,  commonly  in  the  carpus, 
metacarpus,  tarsus,  metatarsus,  less  often  in  the  long  bones  of  the  limbs, 
where  it  may  originate  in  the  juxta-epiphyseal  position,  as  do  the  pyogenic 
infections  ;  but  in  addition  tuberculosis  more  commonly  takes  origin  in 
the  cancellous  bone  under  the  articular  cartilages  and  the  condition  fairly 
soon  involves  the  joint — hence  these  lesions  will  be  considered  under  Tuber- 
culosis of  Joints.  Another  common  seat  of  tuberculosis  is  in  the  cancellous 
bone  of  vertebras.  Tuberculous  periostitis  does  not  seem  at  all  common  as 
the  initial  lesion,  but  of  course  the  periosteum  becomes  involved  as  the 
infection  of  the  cancellous  bone  spreads  outwards.  Tuberculosis  of  bone 
occurs  at  all  periods  of  life,  but  more  commonly  at  the  extremes,  and 
especially  in  infancy  and  childhood.  If  we  exclude  the  infections  starting 
close  to  articular  cartilages,  which  are  considered  imder  Affections  of  Joints, 
the  common  sites  of  these  lesions  are  the  cancellous  tissue  of  short  bones, 
especially  the  wrist,  ankle,  and  spine  ;  the  phalanges,  metacarpals,  and 
metatarsals  are  also  affected  not  infrequently,  while  the  long  bones  but 
rarely  suffer  from  this  disease. 


372  A   i  EXTBOOK  OF  SURGERY 

Pathology.  The  process  is  similar  to  the  formation  of  tubercles  elsewhere. 
Collections  of  proliferating,  fixed  connective  tissue  cells  (here  the  osteo- 
blasts) become  Bpindle  or epitheloid  cells  and  constitute  grey  tubercles;  the 
defeneration  of  these  into  caseous  material  in  their  centres  with  the  forma- 
tion  of  giant  cells  and  the  coalescence  oi  a  number  of  such  tubercles  results 
in  the  formation  of  a  focus  of  caseation.  The  bone  involved  undergoes 
rarefaction  and  caries,  so  that  a  cold  abscess  is  formed  in  the  interior  of 
the  bone.     Later  the  outer,  more  dense,  portion  of  the  bone  is  penetrated, 


Pig.  154. 


Tuberculosis  of  lower  humerus  and  upper  radius,  causing  expansion  of 
i  hese  bones  ami  u  ith  abscess  formation  (child  jet.  4). 


the  periosteum  stripped,  and  a  varying  amount  of  necrosis  results  from 
cutting  off  the  blood-supply,  but  never  on  the  same  massive  scale  as  occurs 
in  the  pyogenic  infections  ;  the  whole  process  is  far  more  gradual. 

'jns.  There  is  pain  and  swelling  of  the  part  affected,  the  former  seldom 
great  but  worse  at  night,  the  swelling  slowly  increasing  without  redness  or 
much  perceptible  heat  at  first.  The  condition  is  that  of  the  "  white  swelling  " 
of  older  pathology.  If  the  process  persists  the  swelling  softens  in  some 
part  of  its  extent  and  fluctuates,  showing  the  presence  of  pus  beneath  the 
periosteum.  Finally  the  skin  over  the  swelling  becomes  involved  and  red, 
the  abscess  bursting  on  the  surface,  leaving  a  sinus  lined  with  anaemic 
granulations  and  leading  down  to  carious  bone.  Such  a  sinus  readily  becomes 
infected  with  other  organisms,  and  the  process  tends  to  spread  slowly, 
involving  neighbouring  bones  and  joints.  The  process  of  disease  is  very 
similar  whether  occurring  in  the  digits,  metacarpals  and  metatarsals  of 
small  children  and  infants  as  "  tuberculous  dactylitis,"  or  in  older  children 


TUBERCULOSIS  OF  BONE  373 

and  adults  in  the  bones  of  the  wrist  and  ankle.  In  the  long  bones  there 
can  be  little  doubt  that  many  cases  regarded  as  tuberculous  are  really 
chronic  pyogenic  infections,  especially  if  there  is  much  sclerosis  about 
the  central  abscess,  for  it  does  not  necessarily  follow  that  because  an  inflam- 
mation is  chronic  that  it  is  therefore  tuberculous. 

Diagnosis.  From  chronic  pyogenic  infections  the  position  of  the  tuber- 
culous lesions  in  the  digits  and  small  bones  of  the  wrist  and  ankle  is  a 
tolerably  safe  distinction  :  when  found  in  the  long  bones  the  absence  of 
sclerosis  will  as  a  rulje  distinguish  the  tuberculous  affection,  but  it  may 
be  impossible  to  make  an  absolutely  certain  diagnosis  till  the  granulations 
of  the  abscess  have  been  examined  for  tubercles  or  the  bacilli.     The  diagnosis 


Fig.  155.     Tuberculosis  of  the  os  calcis  ;    note  the  rarefied  area  behind,  under  the 

epiphyseal  line. 
[Mr.  A.  J.  Walton's  case.) 

from  typhoid  infection  of  bone  is  made  on  the  history  and  serum  reaction, 
&c,  since  clinically  there  is  a  very  close  resemblance  between  these  diseases. 
From  myeloma,  diagnosis  is  only  needed  when  the  long  bones  are  affected. 
In  both  conditions  there  is  rarefaction  with  but  little  sclerosis,  but  the 
tuberculous  lesions  are  more  often  multiple.  The  swelling  in  the  inflamma- 
tory condition  does  not  arise  so  sharply  from  the  normal  bone,  and  in  radio- 
graphs there  is  not  denoted  the  sponge-work  of  bony  trabecular  so  charac- 
teristic of  myeloma,  while  a  formation  of  some  new  bone  under  the  periosteum 
in  concentric  layers  will  be  seen  in  radiographs  to  be  present  in  the  cases  of 
tuberculosis. 

Treatment.  In  the  earlier  stages,  before  there  is  much  breaking  down 
of  the  bone  and  abscess-formation,  the  part  must  be  kept  at  rest  by  encasing 
the  bone  and  neighbouring  joints  in  plaster,  or  some  similar  arrangement, 
e.g.  a  Thomas's  <plint,  to  avoid  jarring  and  the  bearing  of  weight  by  the 


.7  1  \  TEXTBOOK  OF  SURGERY 

affected  limb.    At  the  Bame  time  the  general  condition  is  improved  as  far 

possible  by  outdoor  life,  siinlight,  tatty  food,  cod-liver-oil,  and  iron. 
The  easl  coast,  and  especially  Margate,  lias  a  well -deserved  reputation  in 
the  climatic  treatment  of  the  cases.  In  small  children  mercury  in  small 
doses  proves  a  very  useful  tonic,  being  administered  as  the  grey  powder. 
Passive  congestion  (Bier)  is  of  little  use. 

When  the  infection  has  reached  the  periosteum,  forming  an  abscess,  and 
is  likely  to  hurst  through  the  skin,  the  abscess  should  be  opened  and  carious 
bone  removed,  taking  the  greatest  care  by  antiseptic  precautions  to  prevent 
the  ingress  of  other  pathogenic  organisms.  Since  if  a  secondary  infection 
occurs  the  lesion  will  heal  much  more  slowly  and  is  likely  to  progress  in 
spite  of  treatment. 

The  operation-wound  should  be  sewn  up  and  only  drained  for  twenty- 
four  hours.  In  selected  cases  in  young  subjects  excision  of  the  affected 
part  may  be  advisable;  occasionally  bone-stopping  may  be  useful.  Where 
sinuses  persist  Beck's  bismuth  paste,  30  per  cent.,  is  very  useful.  In  adults 
the  outlook  is  less  good,  and  where  these  lesions  occur  in  those  of  advancing 
years  amputation  is  usually  the  only  resource.  The  healing  of  tuberculous 
lesion  of  bones  is  always  a  slow  matter ;  on  conservative  treatment  it  may 
take  from  six  months  to  two  years  or  more  ;  under  operative  treatment 
healing  may  be  more  speedy,  but  often  this  is  not  the  case.  Many  years 
after  a  focus  of  infection  with  tubercle  bacilli  appears  to  be  healed,  the 
trouble  may  recrudesce  and  a  residual  abscess  form.  In  a  certain  per- 
centage of  cases  spread  will  proceed  in  spite  of  all  treatment,  and  may  lead 
to  general  dissemination  of  the  disease  in  lungs,  meninges,  peritoneum,  &c. 

(Ill)  Syph  Hide  Disease  of  Bone.  Affections  of  bone  due  to  the  spirochete 
occur  in  the  secondary  and  tertiary  stages  as  well  as  in  congenital  syphilis. 
The  processes  are  like  those  of  syphilis  elsewhere,  viz.  an  increase  in  the 
connective  tissue-elements  and  an  endarteritis,  the  result  depending  on 
the  fate  of  the  various  factors  in  the  affection.  Where  the  proliferation 
of  the  connective  tissue-cells  (osteoblasts)  is  great,  but  the  affection  of  the 
blood-vessels  and  the  pressure  of  newly  formed  bone  insufficient  to  cut  off 
the  blood-supply  of  the  tissue,  there  will  result  osteosclerosis,  or  increase 
in  thickness  and  density  of  the  bone  :  if  the  blood-supply  is  much  affected 
the  sclerosed  portion  dies;  this  necrosis  may  be  regarded  as  the  form- 
ation of  a  gumma  in  the  bone,  the  sequestrum  representing  the  central 
slough. 

{a)  In  Secondary  Syphilis.  General  bone-pains  are  common,  presumably 
due  to  slight  affection  of  the  bones,  but  these  subside  under  anti-syphilitic 
remedies.  Of  more  importance  are  the  periosteal  nodes,  found  especially 
on  the  cranium  and  subcutaneous  portion  of  the  tibia,  due  to  a  subacute 
inflammation  of  the  periosteum  and  underlying  bone.  These  lesions,  which 
are  found  as  tend,.]  fusiform  swellings  and  usually  in  the  later  stages  of 
secondary  Byphilis,  when  occurring  in  the  cranium  are  a  source  of  severe 
headache,  which,  like  the  pain  of  bone-disease  generally,  is  worst  at  night. 
Sometimes  there  is  a  deposit  of  new  bone  in  the  inflamed  area  and  a  perma- 


SYPHILIS  OF  BONE  375 

nent  node  results  ;  more  often  they  disappear  on  treatment  with  iodides  and 
mercury,  which  relieve  the  pain  almost  at  once. 

(b)  In  Tertiary  Syphilis.  Here  also  the  cranium  and  long  bones  are 
principally  affected.  In  the  former  there  is  a  formation  of  periosteal  and 
subperiosteal  gummata  with  caries  of  adjacent  bone,  and  often  necrosis  of 
a  considerable  area,  usually  of  the  outer  table,  but  in  some  instances  the 
whole  thickness  of  the  skull  is  involved.  The  gummata  burst  on  the 
surface,  and  the  characteristic  gummatous  ulcers  are  found  with  an  area  of 
bare  bone  in  their  floors.  Secondary  infection  with  pyogenic  organisms 
takes  place,  separation  of  the  sequestra  is  slow,  and  as  there  is  no  formation 
of  new  bone  by  the  pericranium  no  involucrum  forms  over  the  sequestra. 

Treatment.  Specific  treatment  with  mercury  and  iodides,  preceded  by 
a  course  of  neosalvarsan,  is  indicated.  Locally  the  ulcer  should  be  kept 
clean  with  antiseptic  dressings.  If  the  sequestrum  is  large  and  not  separa- 
ting after  two  to  three  months,  it  will  be  best  to  cut  it  away  with  gouge  and 
chisel  till  healthy  bleeding  bone  is  encountered,  for  if  left  the  open  wound 
is  a  constant  source  of  danger  from  further  infection  with  pyogenic  organisms. 
The  more  extensive  cases  of  necrosis  of  the  skull  do  not  seem  to  be  so  common 
now  as  in  former  years :  it  is  uncertain  whether  this  is  due  to  syphilis 
being  of  a  milder  type  at  present,  or  that  the  more  severe  cases  of  necrosis 
were  due  to  the  heroic  doses  of  mercury  given  by  our  forefathers  (see  Diseases 
of  the  Skull). 

In  the  long  bones  the  disease  may  be  localized  or  diffuse. 

(1)  Localized  disease  takes  the  form  of  gummata,  starting  in  the  medulla 
or  cancellous  part  of  the  diaphysis,  and  resulting  in  the*  formation  of  the 
typical  central  slough  with  rarefaction  of  the  bone  around. 

Signs.  There  is  a  fusiform  swelling  of  the  bone  at  the  seat  of  the  gumma, 
but  the  change  in  contour  is  less  sharp  than  in  the  case  of  myeloid  growth. 
Spontaneous  fracture  may  take  place  but  less  often  than  in  cases  of  myeloma, 
since  in  addition  to  the  rarefaction  there  is  often  sclerosis  of  the  bone  as 
well.  Even  with  the  help  of  radiographs  diagnosis  may  be  uncertain  ; 
consequently,  in  the  case  of  a  limb  with  a  doubtful  swelling  of  the  bone 
primary  amputation  should  never  be  done  but  the  swelling  always  explored 
first.  As  a  rule  it  will  be  easy  to  distinguish  macroscopically  between  the 
yellow  shreddy  slough  of  a  gumma  and  the  maroon-coloured  myeloid  or 
the  greyish,  fleshy  mass  of  a  sarcoma,  but  in  doubtful  cases  the  wound 
should  be  closed  and  the  sections  referred  to  the  microscope  for  final  diag- 
nosis. 

Treatment.  Anti-syphilitic  treatment  may  cure  the  condition  in  its 
earlier  stages,  but  when  advanced  it  will  be  best  to  open  the  bone,  turn 
out  the  sloughs  and  sequestra,  scrape  away  carious  bone,  and  fill  the  cavity 
with  sterile  mutton-fat  or  paraffin-wax  and  then  persist  in  the  specific 
treatment. 

(2)  Diffuse  affection  is  usually  of  the  nature  of  osteoperiostitis.  The 
femur  and  tibia  are  favourite  situations,  the  bones  becoming  gradually 
thicker  and  more  dense  over  a  considerable  part  of  their  length.     The 


A  TEX1  BOOK  OF  SURGERY 


affected  bones  arc  somewhat  tender  and  painful,  especially  at  night.    The 
course  ifl  very  chronic  and  the  tendency  to  curvature  is  but  slight. 

'.     If  not  yielding  to  specific  treatment  and  the  pain  being 

distressing,  it  will  he  best  to  cut  down  upon  the  bone  along  the  sclerosed 
part  and  chisel  a  gutter  all  the  length  of  the  affected  portion  right  into  the 

medullary  cavity.  T  his  will 
usually  relieve  the  pain, 
but  resorption  of  the  scle- 
rosed bone  is  unlikely. 

Less  often  a  diffuse 
affection  may  be  of  gum- 
matous nature,  the  bone 
becoming  softer  and  bend- 
ing (mollities  ossium  sy- 
philitica), and  resulting  in 
deformities.  In  such  cases 
splints  are  needed,  and  if 
specific  treatment  alone 
fails,  removal  of  the  gum- 
matous patches  by  oper- 
ation. 

(c)  In  Congenital  Sy- 
philis. The  changes  are 
similar  but  modified  by 
the  fact  that  they  occur 
in  young  growing  tissues. 
In  infants  during  the 
first  and  second  year  we 
find: 

(a)  Craniotabes,  or  de- 
ficient ossification  of  the 
crania]  bones,  which  are 
readily  indented  and  spring 
out  again  like  a  sheet  of  horn  or  celluloid.  Probably  only  some  of  such 
cases  are  of  syphilitic  origin. 

(h)  Parrot's  nodes  or  hypertrophic  osteitis  of  the  cranium.  This  con- 
dition is  found  at  the  comers  of  the  frontal  and  parietal  bone  surrounding 
the  anterior  fontanelle  as  a  thickening  of  these  bones,  giving  the  "  hot-cross- 
bun  "  skull. 

('■)  The  nasal  septum  and  vomer  are  affected  by  rarefaction  and  the 
bridge  of  the  nose  sinks. 

('/)  The  ends  of  the  bones  are  affected  in  the  neighbourhood  of  the 

epiphyseal  line.     The  affection  is  presumably  at  first  spirochetal,  but  a 

:condary  infection  with  pyogenic  organisms  readily  takes  place  and  the 

process  spreads  to  the  joints,  causing  the  acute  arthritis  of  infants  (otherwise 

known  as  syphilitic  pseudo-paralysis  or  syphilitic  epiphysitis). 


156 


genital  syphilitic  sclerosis  and  curving 
of  tibia  (girl  set.  10). 


CONGENITAL  SYPHILIS  OF  BONE 


377 


Signs.  The  patient  is  usually  near  the  end  of  the  first  year  of  life,  when 
suddenly  a  limb  is  noted  to  be  kept  motionless  and  passive  movements  are 
painful,  while  a  painful  swelling  is  found  at  the  end  of  one  of  the  long  bones 
— the  neighbouring  joint  being  often  involved.  This  affection  is  often 
symmetrical,  affecting  the 
knees,  elbows,  wrists  ; 
the  severity  depends  on 
the  quality  of  the  secon- 
dary pyogenic  infection 
and  on  the  amount  of 
disorganization  of  the 
bone  and  joint. 

Diagnosis.  This  dis- 
ease is  readily  distin- 
guished from  rickets  by 
the  earlier  age  of  inci- 
dence and  the  amount 
of  disorganization  of  the 
bone  and  affection  of  the 
joint,  and  by  the  shaft 
•  not  being  affected  ;  from 
infantile  scurvy  by  the 
shaft  not  being  affected 
and  that  the  joint  and  its 
surroundings  quicklysup- 
purate  ;  from  acute  an- 
terior poliomyelitis  by 
the  pain  and  swelling  of 
the  joint  in  the  appar- 
ently paralysed  limb  and 
by  the  multiplicity  of  the 
lesions  in  many  instances. 

Treatment.  Immobi- 
lization and  mercury  may 
cure  the  cases  if  found 
early,  but  where  there  is 
disorganization  of  bone 
and  joint  free  opening, 
drainage,  and  removal  of  sequestra  will  be  needed. as  well  as  specific  treatment. 

(e)  In  older  children,  usually  from  six  to  ten.  there  occurs  a  sclerosing 
osteoperiostitis,  most  usually  of  the  tibia?,  which  appear  to  curve  forwards 
in  their  whole  length — hence  called  sabre  tibiae  ;  the  bending  is  more 
apparent  than  real  owing  to  the  increased  growth  of  dense  bone  in  the 
front  of  the  middle  of  the  tibia,  but  a  slight  amount  of  real  bending  is 
present  as  well.  These  characters  readily  distinguish  the  condition  from 
the  curvature  due  to  rickets. 


Fig.  157.     Sclerosis  of  the  tibiae  and  to  less  degree  of  the 

fibulae  due  to  congenital  syphilis  in  a  girl  of  10  years.     Note 

in  this  view  the  slight  antero-posterior  curve  does   not 

appear. 


A    I  K XT BOOK  »>K  SIRGERY 

Treatment.  Local  treatment  is  seldom  needed,  but  the  condition  indi- 
cates thai  the  disease  is  still  active  and  specific  treatment  is  indicated. 

(IV)  Typhoid  Disease  of  Bone.  Infection  of  bones  may  occur  in  the 
course  of  enteric  fever,  usually  running  a  subacute  course,  seldom 
starting  before  the  third  week  of  the  disease,  and  often  appearing  long  after 
the  acute  disease  is  over.      In  70Ung  subjects  the  lesions  resemble  those  of 

described  in  juxta-epiphyseal  infections,  in  adults  there  is  more  usually  a 
periostitis  with  suppurative  inflammation  of  the  cancellous  bone.  Typhoid 
bacilli  maybe  found  in  pure  culture  in  these  lesions  or  mixed  with  pyogenic 
cocci.  The  bones  commonly  affected  are  the  tibia,  ribs,  and  spine.  The 
affection  may  not  develop  till  years  after  the  attack  of  enteric  fever  is 
over,  the  patient  being  evidently  a  "typhoid-carrier"  in  the  meantime. 
The  more  chronic  cases,  e.g.  typhoid  affection  of  the  spine,  closely  resemble 
infections  with  the  tubercle  bacillus. 

Treatment.  The  chronic  varieties  require  treatment  like  that  for  tuber- 
culous affection,  viz.  rest  in  suitable  splints,  plaster-cases,  &c.  Abscesses 
should  be  opened,  swabbed  out,  purified  with  carbolic,  and  drained  a  few  days. 

In  more  acute  conditions  sequestra  may  need  removal.  The  sinuses 
resulting  from  this  tvpe  of  disease  are  likely  to  become  indolent  and  need 
frequent  scraping,  tilling  with  bismuth  paste,  &c. 

(V)  Hydatid  Disease  of  Bones.  Hydatids  in  bone  occur  but  rarely 
in  this  country,  and  may  grow  in  the  cancellous  or  tubular  part  of  a  long 
bone,  and  it  is  said  may  occur  as  a  collection  of  daughter-cysts  without  a 
surrounding  mother-cyst.  The  growth  of  these  parasites  causes  absorption 
of  the  surrounding  bone,  which  is  expanded,  rising  sharply  from  the  sur- 
rounding bone  after  the  manner  of  an  endosteal  new  growth.  Calcification 
may  take  place  or  the  condition  be  complicated  by  suppuration  around  the 
hydatid. 

Signs.  These  closely  resemble  those  of  an  endosteal  new  growth,  such 
as  a  myeloid  sarcoma,  viz.  a  swelling  rising  abruptly  from  the  surrounding 
bone  in  its  whole  circumference.  Egg-shell  crackling  will  be  noted  as  the 
bone  is  more  thinned  out  over  the  expanding  cyst,  and  spontaneous  fracture 
will  take  place. 

Diagnosis  From  an  endosteal  growth  physical  signs  will  be  of  little 
help,  but  in  a  radiograph  the  spongy  meshwork  of  bone  seen  in  a  new  growth 
will  not  be  present  in  the  hydatid  tumour  ;  from  simple  bone-cysts  (osteitis 
fibro-cystica)  the  greater  expansion  of  the  bone  in  the  hydatid  will  differen- 
tiate, but  in  many  cases  exploration  is  needed. 

Treatment.  Earlv  exploration  of  all  cysts  is  the  basis  of  satisfactory 
treatment.  If  the  bone  is  not  too  badly  destroyed  after  evacuation  of  the 
hydatid  the  bone-wound  may  be  closed,  with  temporary  drainage,  or  some 
plan  of  "bone-stopping"  adopted.  If  there  is  great  destruction  of  the 
bone  t  he  wound  should  be  allowed  to  heal  and  then  bone-grafting  assiduously 
employed.  Amputation  should  only  be  needed  when  severe  suppuration 
is  taking  place,  and  life  appears  to  lie  endangered,  or  if  repeated  attempts 
at  bone-grafting  fail  to  produce  a  useful  limb. 


OSTEOMA 


379 


New  Growths  and  Cysts  of  Bone.  These  may  be  primary,  i.e.  those 
which  originate  in  bone,  and  secondary  or  metastatic  deposits  from  malignant 
growths  elsewhere. 

Primary  tumours  of  bone  may  be  divided  in  the  first  place  into  those 
which  grow  from  the  exterior  of  the  bone — (1)  exosteal  or  periosteal  growths 
— and  those  which  originate  inside 
the  bone — (2)  endosteal  or  myeloid 
tumours. 

(a)  Exosteal  Tumours.  These 
may  further  be  divided  into  inno- 
cent and  malignant.  Of  innocent 
exosteal  growths  the  only  forms  at 
all  common  are  osteomas  and 
chondromas  :  lipomas  also  are 
found  and  are  important  in  diag- 
nosis. Of  malignant  periosteal 
tumours  sarcomas  and  occasion- 
ally endotheliomas  are  found. 

(1)  Osteomas  are  of  two  main 
varieties,  the  cancellous  and  the 
dense  or  ivory  exostoses ;  the 
latter  are  found  only  in  the  skull 
and  are  described  in  that  section. 

Cancellous  osteomas  (exosto- 
ses). These  always  appear  in 
childhood  or  adolescent  life  in  the 
neighbourhood  of  the  epiphyseal 
line  of  long  bones,  and  are  capped 
with  cartilage  which  forms  their 
growing-point.  In  fact,  the  carti- 
lage-cap represents  the  epiphyseal 
cartilage  of  the  exostosis.  It  is 
uncertain  how  such  portions  of  epi- 
physeal cartilage  take  on  this  func- 
tion, but  rickets  is  often  held  responsible.  These  tumours  are  usually  multi- 
ple and  often  hereditary.  Exostoses  may  attain  a  considerable  size  and  even 
become  pedunculated  :  their  direction  of  growth  is  away  from  the  end  of  the 
bone  at  which  they  are  situated,  thus  forming  an  overhanging  edge  on  this  side 
of  the  growth,  which  is  characteristic  of  exostoses  (Fig.  158).  Bursa?  commonly 
form  over  these  tumours.  Exostoses  cease  to  grow  about  the  time  that  the 
epiphyses  unite  with  the  shaft,  and  only  cause  trouble  owing  to  their  position 
by  pressing  on  vessels  or  nerves  or  interfering  with  movements  of  joints. 

Treatment.  This  consists  in  removing  the  tumour  with  chisel  or  saw, 
rendering  the  base  level  with  the  shaft  of  the  bone. 

Subungual  Exostosis.  A  favourite  site  for  growth  of  an  exostosis  (apart 
from  the  end  of  long  bones)  is  from  the  last  phalanx  of  the  great  toe  on  the 


Fig.  158.     Large  exostosis  of  the  lower  femur 
in  a  youth  of  1 7  (skiagram). 


\  TEXTBOOK  OF  SURGERY 

dorsal  surface,  under  the  nail.  The  reason  of  these  growths  is  uncertain  ; 
repeated  trauma  has  hern  suggested  as  cause,  but  as  the  growth  is  capped 
with  cartilage  it  is  probably  due  to  some  congenital  error.  The  condition  is 
readily  recognized  as  a  hard.  pale,  non-inflammatory  swelling  of  slow  growth 
pushing  up  the  nail  of  the  great  toe  in  young  persons,  causing  pain  from 
the  pressure  on  the  sensitive  nail-bed. 

Treatm  nt  consists  in  removing  the  nail  and  chiselling  away  the  growth. 
Exostoses  tunning  in  tendons,  as  "rider's  bone,"  which  appears  in  the 
tendon  of  the  adductor  ma  gnus  in  those  who  ride  much,  or  the  "  drill-bone  " 
found  in  the  deltoid  of  soldiers  (from  blows  with  the  rifle  in  "  shouldering 
arms  ")  are  probably  of  inflammatory  nature  and 
akin  to  "  myositis  ossificans."      If  causing  incon- 
venience such  bony  formations  may  be  removed. 
Diffuse    formation   of   cancellous  bone  in  the 
facial  bones  has  been  already  mentioned  (leontiasis 
H     ossea).    The  cause  is  unknown.     When  the  con- 
dition is  advanced  the  cheeks  project  on  either  side 
of  the  nose,  which  is  relatively  sunken  and  hidden 
by  the  projecting  masses  on  either  side  ;    so  that 

in  severe  instances  the  face  may  closely  resemble 
tosis,  great  toe  (skiagram).  J  .    J 

the  buttocks.  As  the  eye  may  be  displaced,  and 
for  cosmetic  reasons,  removal  of  such  tumours  with  chisel  and  saw  is 
usually  indicated  sooner  or  later. 

(2)  Chondromas.  Apart  from  the  ossifying  cartilage-caps  of  exostoses 
or  chondrification  arising  in  a  sarcoma  these  tumours  are  not  common, 
and  are  hardly  ever  found  except  growing  from  the  metacarpals  and  phalanges 
of  the  hand — very  rarely  from  corresponding  bones  of  the  foot.  The  origin 
of  these  tumours  is  obscure ;  it  is  generally  considered  that  congenital 
defects  in  the  ossification  of  the  primitive  cartilaginous  basis  of  the  diaphysis 
of  these  bones  is  the  cause,  as  they  appear  in  children  and  adolescents. 
They  are  frequently  multiple  and  may  cause  great  deformity  and  disability 
as  they  increase  in  size. 

Signs.  The  appearance  of  several  hard  lumps  growing  very  slowly 
from  the  bones  of  the  hand  in  young  persons,  causing  no  pain  unless 
pressing  on  nerves,  is  sufficient  to  make  the  diagnosis. 

Treatment  consists  in  removing  the  tumours  by  operation  if  they  are 
causing  any  trouble,  or  are  likely  to  do  so,  from  their  position.  As  they 
tend  to  spread  into  the  interior  of  the  bones,  from  which  they  grow,  and 
cause  pressure-atrophy,  they  should  be  scooped  out  or  enucleated  rather 
than  cut  off  the  surface  of  the  bone. 

(3)  Lipomas,  and  less  frequently  fibromas,  arising  from  the  outside  of 
bones,  i.e.  from  the  periosteum,  are  of  importance  from  their  liability  to  be 
mistaken  for  the  more  common  sarcomas.  Their  slower  growth,  better 
defined  edge,  and  the  lobulation  which  may  be  felt  in  the  case  of  lipomas, 
will  help  to  distinguish  from  the  more  important  and  dangerous  sar- 
comas, but  their  occurrence  shows  the  importance  of  exploring  periosteal 


SARCOMAS  OF  BONE 


381 


tumours  before   proceeding   to   such   drastic   measures  as  amputation  of 
a  limb. 

Growing  from  the  periosteum  of  the  jaw,  as  Epulis,  or  that  of  the  naso- 
pharynx, as  Naso-pharyngeal  Fibromas,  there  occur  tumours  of  partial 
malignancy  sometimes 
described  as  fibromas, 
though  appearing  mi- 
croscopically to  be  more 
related  to  spindle-celled 
sarcomas.  These  tu- 
mours are  of  relatively 
low  malignancy  and 
seldom  form  metasta- 
ses, but  spread  locally 
and  recur  unless  re- 
moved freely. 

(4)  Sarcomas.  Grow- 
ing from  the  outside 
of  bones,  i.e.  from  the 
periosteum,  sarcomas 
are  formed  of  round 
or  spindle  cells,  and 
usually  take  origin  in 
the  deeper  (osteoge- 
netic)  layer  of  the  peri- 
osteum ;  hence  new 
bone  is  often  formed 
during  their  growth. 
Less  often  sarcomas 
originate  in  the  more 
superficial,  fibrous  lay- 
ers of  the  periosteum 
and  have  no  tendency 
to  develop  bone  in 
their  structure  (peri- 
osteal sarcomas).  The 
malignancy  of  these 
tumours  is  great :  their 
line  of  spread  is  into 
the  surrounding  tissues, 
especially  muscle,  but  also  into  lymphatics  and  veins,  causing  metastases 
in  lungs  and  lymph-nodes  ;  the  bone  is  invaded  later  and  may  undergo 
spontaneous  fracture.  These  growths  may  surround  the  bone  evenly,  but 
often  project  more  from  one  surface.  The  malignancy  seems  to  vary  with 
the  situation  of  the  growth.  Thus  cases  are  recorded  where  local  removal 
of  such  tumours  from  the  distal  parts  of  limbs,  e.g.  the  tibia  or  radius,  has 


Fig.  160.    Periosteal  sarcoma  (X-ray)  of  the  humerus,  with 

considerable    destruction    of    bone;     note    the     radiating 

manner  in  which  new  bone  is  laid  down  in  the  tumour. 

{Kindly  lent  by  Mr.  A.  J.  Walton) 


\  TEXTBOOK  OK  srROKRY 

been  successful ;  when,  however,  they  occur  in  the  femur  or  humerus  death 
from  metastases  seems  to  be  invariable,  eveD  it'  amputation  as  high  as 
possible  (at  the  hip  or  the  interscapulo-thoracic  operation)  be  done. 

S  jns.  A  Lump,  painless  at  first,  is  found  growing  rapidly  from  the  shaft 
of  a  long  bone  usually  towards  one  end.  The  swelling  rises  abruptly  from 
the  surrounding  bone  and  is  seldom  of  bony  hardness,  but  may  be  harder 
in  some  parts  ;  later,  areas  of  softening  and  fluctuation,  and  sometimes 
egg-shell  crackling,  are  noted.  Fever  is  not  present  till  later,  when  metas- 
tatic deposits  have  impaired  the  general  health.  As  the  tumour  grows 
enlargement  of  the  superficial  veins  and  oedema  of  the  skin  over  the  growth 
are  found  :  sometimes  spontaneous  fractures  occur.  Later  enlargement  of 
lymphatic  glands  may  be  present  and  metastases  in  the  lung  are  found, 
evidenced  by  cough,  haemoptysis,  dyspnoea, .and  areas  of  consolidation  of 
the  lung  or  pleural  effusion. 

Diagnosis.  From  lipomas  or  fibromas  originating  in  the  periosteum  the 
greater  rapidity  of  growth,  the  partial  ossification  with  perhaps  egg-shell 
cracklinir.  ami  irregularity  in  texture,  as  well  as  alteration  in  the  bone  as 
seen  with  X-rays  (either  rarefaction  from  pressure  or  ossification  of  the 
tumour  in  a  radial  manner),  will  decide  in  favour  of  sarcoma.  From  exos- 
toses, the  greater  hardness  of  the  latter  and  the  much  slowrer  growth  and 
the  absence  of  enlarged  veins  are  in  favour  of  exostosis.  The  character  of 
the  edge  is  of  importance,  and  exostosis  presents  a  sharp  and  sometimes 
overhanging  edge  away  from  the  end  of  the  bone  near  to  which  the 
tumour  is  growing,  but  trends  gradually  down  to  the  epiphysis  ;  while  a 
sarcoma  rises  sharply  on  either  side  from  the  shaft  of  the  bone,  and  seldom 
does  the  edge  of  these  tumours  overhang. 

From  inflammatory  conditions  such  as  chronic  abscess  of  the  cancellous 
tissue  of  the  diaphyseal  end  (Brodie)  or  chronic  osteoperiostitis  (e.g.  syphilitic), 
the  night  pain  of  the  latter,  the  more  gradual  fusiform  rise  in  the  swelling 
at  its  extremities,  the  irregular  pyrexia,  in  some  instances,  and  when  super- 
ficial the  signs  of  inflammation  in  the  skin,  should  differentiate  ;  but  in 
early  cases  radiographs  afford  the  best  means  of  diagnosis.  If  the  condition 
is  inflammatory  there  will  be  a  deposit  of  new  bone  under  the  periosteum 
in  layers  parallel  to  the  axis  of  the  bone  ;  whereas  in  sarcoma,  if  newr  bone 
is  formed,  then  this  is  laid  down  as  radial  striations  at  right-angles  to  the 
axis  of  the  bone  (Scott).  Later  this  radial  arrangement  of  bone  in  an 
ossifying  sarcoma  is  obvious  if  thetumour  be  incised.  Treatment  is  discussed 
later. 

(b)  Endosteal  Tumours.  Tumours  in  this  situation  may  be  divided 
into  myeloid  sarcomas,  mixed  sarcomas,  cysts,  and  pulsating  tumours — 
myeloid  tumours  and  cysts  being  the  most  usual  conditions. 

(1)  Myeloid  Tumows.  The  tumours  referred  to  here  are  those  known 
as  giant-celled  sarcomas  or  myeloid  sarcomas,  sometimes  myelomas  :  the 
reader  is  referred  to  the  section  on  General  Pathology  for  a  short  account 
of  the  condition,  Myelomatosis,  and  the  rare  condition  Chloroma  may  be 
briefly  mentioned  here. 


GIANT -CELLED  SARCOMA 


383 


Chloroma.  In  this  disease  there  is  an  infiltration  and  an  enlargement  of 
the  bones,  especially  of  the  base  of  the  skull,  with  lymphocytes  leading 
to  enlargement  of  these  bones,  which  are  of  a  greenish  colour.  There 
is  a  marked  lymphatic  leukaemia,  and  the  deposits  in  the  bones  are  to 
be  regarded  as  secondary  deposits  from  this  general  disease  of  the  blood 
and  quite  outside  sur- 
gical measures. 

Myeloid  or  Giant- 
celled  Sarcomas.  These 
tumours  originate  in 
the  cancellous  ends 
of  long  bones  and  are 
built  up  of  a  basis  of 
spindle-cells  contain- 
ing very  large  numbers 
of  multinucleate  giant 
cells,  which  on  section 
form  the  most  charac- 
teristic feature  of  the 
picture.  Macroscopi- 
cally  these  growths  are 
homogeneous  and  of 
maroon  colour,  like 
red-currant  jelly.  For 
the  most  part  these 
tumours  are  of  only 
local  malignancy  and 
do  not  form  metasta- 
ses, though  cases  of 
metastases  are  reported 
from  tumours  appa- 
rently of  this  nature, 
occurring  in  the  femur 
and  humerus.  One 
would  regard  such  dis- 
seminating or  malig- 
nant forms  as  ordinary  sarcomas  which  happen  to  contain  a  number  of 
giant  cells  rather  than  as  true  giant-celled  sarcomas,  but  it  is  hard  to 
differentiate  the  innocent  from  the  malignant  by  present  methods  of 
microscopical  investigation.  Giant-celled  sarcomas  are  found  in  early 
adult  life  according  to  Bloodgood,  being  rare  before  twenty ;  they  are 
found  in  the  lower  end  of  the  femur,  upper  end  of  the  tibia,  upper  end 
of  the  humerus,  and  most  commonly  (Bloodgood)  in  the  lower  end  of  the 
radius  :  the  lower  jaw  is  another  favourite  situation,  where  they  appear  as 
the  purple  epulis. 

These  tumours  grow  much  more  slowly  than  ordinary  sarcomas  and  the 


Fig.  161.    Myeloid  sarcoma  of  the  upper  end  of  the  humerus 

(X-ray),  snowing  expansion  and  rarefaction  of  the  bone. 

[Kindly  lent  by  Mr.  A.  J.  Walton.) 


\  TEXTBOOK  OK  -I  RUKKY 

bone  is  expanded  in  all  directions  by  pressure  atrophy,  bo  that  spontaneous 
fractures  are  Dot  uncommon. 

Slight  pain  of  boring  character  followed  alter  a  considerable 

time  by  a  globular  swelling  of  the  whole  bone  near  one  end,  which  rises 
abruptly  from  the  surrounding  shaft ;  later  distension  of  the  superficial 
veins,  egg-shell  crackling  and  pulsation  are  fairly  often  noted. 

In  the  early  stages  diagnosis  can  hardly  be  made  without  the  use  of 
X-rays.  In  a  radiograph  the  place  of  the  tumour  shows  as  a  clear  area 
towards  the  end  of  the  bone,  which  is  atrophied  by  pressure  at  this  part; 
there  is  no  surrounding  periosteal  format  ion  of  new  bone  as  in  inflammatory 
conditions,  with  which  the  lesion  may  be  readily  confused.  The  clearly 
localized  destruction  of  the  bone  helps  to  distinguish  from  ordinary  sarcomas 
growing  inside  bones,  since  these  spread  up  and  down  the  bone  as  well  as 
burst  through  side-ways.  In  later  cases  radiographic  examination  will 
show  in  an  interlacing  meshwork  of  bony  trabeculae  which  appear  to  per- 
meate the  tumour,  but  stereoscopic  examination  shows  that  this  formation 
of  bone  is  on  the  surface  of  the  tumour  and  not  in  its  interior,  which  is  free 
from  deposit  of  bone  (Scott). 

(2)  Endosteal  sarcomas  are  of  round  or  spindle-cells,  often  mixed  with 
giant  cells,  rendering  their  distinction  from  true  giant-celled  sarcoma  often 
tar  from  easy  ;  these  are  less  common  than  giant-celled  tumours  proper. 
These  growths  spread  up  and  down  the  bone  more  than  the  former  group, 
and  when  bursting  through  the  wall  of  the  bone  infiltrate  surrounding  tissues 
as  do  other  sarcomas,  forming  metastases  in  glands  and  lungs.  They  are 
on  the  whole  less  malignant  than  are  periosteal  sarcomas. 

Endotheliomas,  peritheliomas,  and  other  varieties  of  vascular  and  often 
pulsating  sarcomas  are  described,  tending  in  many  cases  to  form  metastases 
and  often  requiring  the  microscope  to  distinguish  them  from  giant-celled 
growths. 

(3)  Cysts  of  Bone,  Osteomyelitis  Cystica  Fibrosa  (v.  Recklinghausen). 
This  disease  consists  of  a  process  of  rarefaction  in  bones,  the  osseous  tissues 
becoming  replaced  by  fibrous  material  in  which  cysts  are  very  often  found. 
The  long  bones  are  most  affected,  especially  the  upper  part  of  the  humerus. 
The  patches  of  fibrosis  and  cyst-formation  may  be  single  or  multiple  and 
are  found  in  young  subjects,  being  uncommon  over  twenty  years  of  age. 
These  cysts  contain  thin  fluid  of  yellow  or  brownish  colour,  and  sometimes 
giant  cells  or  cartilage  cells  are  found  in  the  walls  of  the  cyst. 

Signs.  The  rarefaction  of  the  bone  may  lead  to  spontaneous  fracture,  and 
a  radiograph  will  show  the  nature  of  the  disease  ;  in  other  instances  the  con- 
dition is  noted  by  chance  in  radiographs  taken  for  other  disease  or  injury. 

Diagnosis.  The  condition  somewhat  resembles  a  myeloid  growth  in  so 
far  that  there  is  a  rarefied  area  in  the  bone,  but  this  is  generally  less  near 
the  end  of  the  bone  and  is  of  more  elongate  shape  than  is  a  myeloid  growth, 
which  is  more  globular  ;  also  in  the  cyst  there  is  very  little,  if  any,  expansion 
of  the  bones  ;  nor  is  I  here  the  meshwork  of  new  bone  in  the  periphery  of  the 
rarefied  area  noted  in  giant-celled  sarcomas. 


TREATMENT  OF  SARCOMAS  OF  BONE 


385 


t 


Treatment.  The  cyst  should  be  opened,  its  contents  evacuated,  and  the 
wall  well  scraped ;  the  cavity  may  be  filled  with  some  form  of  "  bone 
stopping."  The  prognosis  is  very  good  under  such  treatment,  the  destroyed 
bone  becoming  replaced  and  a  useful  limb  resulting.  Where  there  is  much 
destruction  of  the  bone  the  part  removed  should  be  replaced  by  a  vulcanite 
rod  inside  the  periosteum  to 
form  an  internal  splint,  around 
which  the  new  shaft  forms. 

Cysts  also  occur  in  bone 
from  degeneration  of  chondro- 
mas, giant-celled  sarcomas,  and 
other  sarcomas.  The  cause  of 
the  v.  Recklinghausen's  cystic- 
disease  is  unknown ;  some  con- 
sider it  to  be  a  form  of  Paget  "s 
disease  (osteitis  deformans)  in 
young  subjects,  since  cysts  also 
occur  sometimes  in  the  latter 
disease. 

Pulsating  Tumours  of  Bone. 
As  will  be  gathered  from  the 
above  account,  pulsation  may 
occur  in  various  endosteal  tu- 
mours (less  often  in  exosteal 
growths),  depending  on  their 
vascularity.  These  are  to  be 
distinguished  from  aneurysms 
if  found  in  the  neighbourhood 
of  a  large  artery.  Compres- 
sion of  the  artery  above  will 
stop  the  pulsation  in  either 
case,  but  while  the  sac  of  an 
aneurysm  can  be  emptied  to 
some  degree,  the  pulsating  tu- 
mour of  bone  can  be  but  little 
altered  in  this  manner.  Radiographs  will  be  useful  in  doubtful  cases. 
Occasionally  such  tumours  of  bone  are  due  to  the  formation  of  Cirsoid 
aneurysms  or  Aneurysm  by  Anastomosis,  but  more  often  are  the  result  of 
breaking  down  of  giant-celled  or  other  forms  of  sarcoma. 

Treatment  of  Giant-cdled  and  other  Sarcomas  of  Bone.  From  the  above 
short  description  it  will  be  seen  that  our  knowledge  of  the  pathology  of 
bone  tumours  is  very  incomplete,  and  consequently  the  prognosis  and 
necessary  treatment  are  often  uncertain.  There  are  three  main  points 
demanding  consideration  :  (a)  the  kind  of  tumour  present  ;  (6)  the  extent 
to  which  it  has  spread  and  involved  surrounding  tissues  ;  (c)  the  importance 
to  the  patient  of  the  part  involved.  In  all  doubtful  cases  a  microscopical 
1  2; 


I 


Fig.  162.  Bone  cyst  (osteitis  cystica),  upper  humerus, 
boy  of  14.     Note  rarefaction  of  the  bone  without  ex- 
pansion or  surrounding  periostitis. 


A  TEXTBOOK  OF  SURGERY 

examination  should  be  made  while  the  patient  is  still  on  the  operating- 
table,  before  the  line  of  treat  incut  is  settled;  only  in  this  way  can  we, 
in  many  instances,  avoid  such  disasters  as  amputating  a  limb  contain- 
ing an  inflammatory  mass  in  mistake  for  sarcoma  or  treating  a  sarcoma 
as  leniently  as  a  giant-celled  myeloma. 

Myeloid  or  Giant-celled  Sarcomas.  In  these  cases  conservative  measures 
have  been  followed  by  great  success.  Erasion  or  scraping  out  the  tumour 
is  indicated  when'  the  condition  is  discovered  early  and  the  bone  is  not 
much  destroyed,  so  that  it  will  not  collapse  from  the  weight  of  the  limb 
after  operation.  The  hone  over  the  tumour  is  freely  exposed  and  opened, 
the  contents  of  the  tumour-mass  removed  with  gouge  and  sharp  spoon  till 
healthy  hone  is  reached,  the  interior  painted  with  pure  carbolic  and,  after 
checking  haemorrhage  with  hot  water,  dried  and  a  filling  of  paraffin-wax  or 
mutton-fat  poured  in.  the  wound  being  closed  in  layers.  In  the  case  of  the 
lower  jaw  removal  of  the  affected  alveolar  margin  will,  as  a  rule,  suffice. 
Where  the  bone  is  greatly  expanded  so  as  to  form  a  mere  shell  which  will 
surely  collapse  after  the  tumour  is  removed,  the  portion  involved  should  be 
resected,  taking  care  to  scrutinize  the  medulla  at  the  ends  of  the  section 
that  no  diseased  part  may  be  left  behind.  The  intervening  space  in  the 
upper  limb  may  he  tilled  with  hone-grafts  taken  from  the  fibula,  but  in  the 
lower  limb,  e.g.  at  the  knee,  it  is  not  easy  to  get  a  sufficient  number  of  strong 
grafts  requisite  to  form  a  stable  limb,  and  it  may  be  better  practice  to  bring 
the  femur  and  tibia  together  and,  later,  obviate  the  shortening  of  the  limb 
with  a  high  boot. 

Where  the  growl  h  has  burst  outside  the  bone  and  is  invading  surrounding 
tissues  the  (piot ion  of  amputation  must  be  considered.  If  a  wide  resection 
is  likely  to  result  in  a  useless  limb  amputation  is  indicated,  but  where,  there 
me  hope  of  obtaining  a  serviceable  limb  by  resection  this  should  be 
practised  except  in  tumours  of  the  upper  femur  or  humerus,  where  the 
chance  of  metastases  seems  sufficiently  great  to  warrant  amputation  at 
the  hip  or  the  interscapulo-thoracic  situation. 

Sarcomas.  The  treatment  of  these  tumours,  whether  periosteal  or 
endosteal,  still  forms  one  of  the  dark  passages  of  surgery. 

It  does  not  seem  that  amputation  high  above  periosteal  sarcomas  is 
any  guarantee  of  Don-recurrence  or  even  that  the  patient's  life  will  be 
prolonged.  Certain  cases  in  the  extremities  of  the  limbs  are  cured  by 
amputation  well  above  the  growth,  but  just  about  as  many  have  been  cured 
by  local  resection.  We  are  therefore  in  favour  of  reserving  amputation 
for  cases  where  wide  resection  is  not  feasible  or  where  the  limb  is  greatly 
damaged,  so  that  resection  of  the  tumour  will  result  in  a  useless  limb  or 
where  the  condition  is  painful  and  the  limb  useless. 

Whether  amputation  or  resection  be  practised  the  glands  of  the  axilla 
or  groin  should  be  carefully  dissected  away,  as  the  bulk  of  evidence  is  in 
favour  of  these  being  not  infrequently  affected.  After  resection  the  site 
of  the  growth  should  be  exposed  to  hc;i\y  doses  of  X-rays  passed  through 
an  aluminium  screen. 


METASTATIC  TUMOURS  OF  BOXE  387 

Ir  the  tumour  be  in  a  place  where  removal  is  impossible,  e.g.  widely 
spread  in  the  pelvis  or  jaws,  palliation  in  many  rases  and,  in  rare  instances, 
cure  may  be  effected  by  the  use  of  heavy  doses  of  X-rays  and  of  Coley's  fluid, 
though  the  latter  agent  appears  less  potent  for  good  in  this  country  than 
in  America.  Another  plan  which  may  be  of  service,  and  which  can  be  used 
in  addition  to  the  above  methods,  is  to  diminish  the  blood-supply  of  the 
tumour.  Thus,  in  a  case  of  inoperable  sarcoma  of  the  jaw  and  temporal 
region  ligature  of  the  external  carotid  artery  after  injection  of  boiling  water 
into  the  vessel,  followed  by  the  use  of  X-rays  and  Coley's  fluid,  resulted  in 
complete  disappearance  of  the  growth  for  a  time.  Seeing  how  poor  are 
the  results  of  pure  surgery  in  these  cases,  there  can  be  little  doubt  that 
in  the  future  the  main  therapy  of  these  growths  will  be  by  means  of  rays, 
sera,  drugs,  Arc.  rather  than  in  the  use  of  the  crude  knife,  though  assistance 
from  the  latter  is  invaluable  at  times. 

Skcoxdary  Tumours  of  Bone.  These  may  be  (a)  from  invasion  in 
continuity,  as  where  an  epithelioma  of  the  gum  or  tongue  invades  the  jaw, 
or  (h)  by  metastasis,  as  when  the  spine  or  humerus  is  infected  from  a  cancer 
of  the  breast.  All  sorts  of  cancer  will  give  rise  to  metastases  in  the  bones 
if  the  patient  lives  long  enough,  including  spheroidal  cancer  of  the  breast, 
columnar  cancer  of  the  rectum,  growths  of  the  thyroid,  prostate  and  adrenal 
mes  (theliomas,  &c.  In  some  instances  the  secondary  deposits  in  bones 
are  noted  before  the  primary  growth  is  large  enough  to  produce  any  marked 
signs;  therefore  in  all  cases  of  tumours  of  bone  the  thyroid,  prostate  and 
breast  should  be  examined  lest  a  useless  operation  be  performed.  The 
metastases  may  be  (a)  localized,  leading  to  atrophy  of  the  bone  at  the 
site  of  the  metastasis  followed  by  spontaneous  fracture,  or  (h)  a  more  general- 
ized infection  of  bones  may  occur,  followed  by  softening  and  bending  of 
the  latter  (cancerous  osteomalacia).  Secondary  infection  of  bones  with 
sarcoma  also  occurs,  especially  where  the  tumour  is  of  the  melanotic  variety. 

Diagnosis.  Secondary  cancer  of  bone  is  diagnosed  by  patient  searching 
for  the  primary  affection.  Thus  in  case  of  pulsating  tumour  of  the  skull 
the  thyroid  should  be  excluded  before  considering  the  growth  to  be  primary. 
In  tumours  of  tin1  vertebra?,  ribs,  humerus,  and  femur  the  breast  will  need 
examination  ;    nor  should  the  prostate  and  rectum  be  neglected. 

Where  secondary  growths  of  bones  are  of  metastatic  nature,  treatment 
is  seldom  needed  unless  spontaneous  fracture  takes  place,  when  splints  are 
indicated  as  in  simple  fractures,  and  union  will  fairly  often  take  place. 
Where,  however,  the  secondary  invasion  is  in  continuity  with  the  primary 
growth  operative  measures  may  be  possible  and  desirable.  Thus  part  of 
the  jaw  may  be  removed  in  boring  epithelioma  of  the  gum.  and  in  some 
cases  where  the  growth  has  spread  there  from  the  tongue. 

OPERATIONS  ON  BONES 
Various  methods  of  fastening  bones  together  with  pegs,  screws,  plates, 
and  wires  have  already  been  discussed  in  the  section  on  Fractures,  and  need 
no  further  mention  except  to  point  out  that  any  of  these  methods  may  be 


\  TEXTBOOK  OF  SURGERY 

•  >f  use  in  casea  of  removal  of  portions  of  bone  for  disease  to  ensure  the 
portions  left  remaining  in  good  position,  or  to  retain  a  bone-graft  in  place. 

Osteotomy.  This  implies  cutting  across  a  bone  to  correct  some  defect 
in  the  direction  of  its  axis,  whether  curvature  or  twisting  or  overgrowth 
of  one  side  of  the  hone,  as  in  the  case  of  knock-knee  of  adolescents. 

Two  forms  are  practised  :   (d)  the  linear  ;   (b)  the  cuneiform. 

(a)  Linear  or  subcutaneous  osteotomy  is  a  simple  operation  and  akin 
to  subcutaneous  tenotomy.  The  division  of  the  bone  is  made  with  an 
osteotome,  which  is  a  sort  of  chisel,  bevelled  however,  on  both  sides  ami 
having  a  scale  in  fractions  of  an  inch  engraved  on  one  side  to  show  the 
depth  of  penetration  and  avoid  driving  the  instrument  through  the  limb. 
The  limb  is  placed  on  a  sand-bag  and  the  bone  reached  by  a  short  J-  to  f-in. 
incision  in  the  direction  of  its  axis  over  the  point  to  be  divided.  The 
incision  passes  right  down  to  the  bone.  The  osteotome  is  introduced  and 
rotated  so  that  its  edge  is  across  the  bone.  The  bone  is  cut  through  with 
this  instrument  driven  by  blows  of  the  mallet,  testing  the  amount  cut 
through  by  feeling  with  the  end  of  the  osteotome  till  about  three-quarters 
or  more  of  the  bone  is  divided,  when  by  bending  the  bone  away  from  the 
cut  surface  the  remainder  should  fracture  readily.  The  small  wound  is 
closed  with  a  suture  and  the  limb  placed  in  corrected  position  on  a  splint 
for  ten  days  and  then  fully  corrected  in  plaster  for  six  weeks.  This  operation 
is  chiefly  used  at  the  lower  end  of  the  femur  for  knock-knee. 

(I>)  Cuneiform,  or  open  osteotomy,  consists  in  exposing  the  hone  freely 
and  removing  a  suitable-sized  wedge  with  osteotome  or  sawr  to  permit  of 
straightening  of  the  bone.  The  fragments  are  fixed  in  position  with  plate 
or  screw  or  simply  with  splints  and,  later,  plaster.  The  usual  place  for 
this  operation  is  the  knee  when  ankylosed  in  bad  position,  but  the  upper 
end  of  the  femur  maybe  treated  in  this  way  for  coxa  vara,  or  the  bones  of 
the  tarsus  for  inveterate  club-foot.  Manual  Osteoclasis  is  described  under 
Curvature  of  the  Tibia. 

Kesection  of  Bones.  Bones  may  be  resected  or  excised  partially  or 
completely  with  or  without  their  periosteum.  Complete  resections  of  bone 
•Mom  done  except  in  the  case  of  the  scapula,  clavicle,  and  astragalus,  as 
in  most  cases  the  impairment  of  function  would  be  too  great.  Resection 
of  the  bone  with  periosteum  is  done  for  new  growths,  while  subperiosteal 
resections  are  more  useful  for  infective  disease,  especially  of  pyogenic  origin. 
<  oniplete  subperiosteal  resection  or  Diaphysectomy  is  useful  in  the  treatment 
ol  acute  infective  disease  :  such  resection  of  the  diaphysis  may  be  performed  . 

(<>)  In  the  acute  stage  of  the  disease  where  there  is  severe  toxic  absorp- 
tion, to  ensure  good  drainage  and  remove  an  infective  focus,  as  has  already 
been  described  {see  Infective  Diaphysitis,  p.  369). 

(b)  After  the  sequestrum  is  separated  and  is  surrounded  by  the  involu- 
crum  of  newly  formed  periosteal  bone  (sequestrotomy). 

In  either  case  the  operation  consists  in  exposing  the  bone  along  its  most 
superficial  aspectj  opening  the  periosteum  or  involucrum  by  a  longitudinal 
incision  and  removing  the  diaphysis  or  sequestra!  remains  of  the  latter, 


OPERATIONS  ON  BONES  389 

draining  with  a  gauze  pack,  or  if  the  periosteum  tends  to  collapse,  as  happens 
in  acute  cases,  placing  a  vulcanite  rod  to  take  the  place  of  the  diaphysis  and 
preserve  the  length  of  the  bone  and  prevent  the  periosteal  walls  from  falling 
together. 

Local  resection  of  bone  with  its  periosteum  is  called  for  in  the  case  of  a 
giant-celled  sarcoma  destroying  a  segment  of  the  bone.  The  gap  left  is 
filled  in  various  ways  ;  portions  of  rib,  fibula,  or  a  slice  of  tibia  may  be 
inserted,  or  the  remainder  of  the  bone  may  be  split  longitudinally  and  one 
part  drawn  into  the  gap. 

Repair  of  Defects  in  Bones.  Two  sorts  of  conditions  present  them- 
selves :  (a)  where  a  cavity  has  been  made  in  a  bone  to  remove  such  things 
as  chronic  abscesses,  cysts,  myeloid  sarcomas,  &c.  ;  (6)  where  the  whole 
thickness  of  some  part  of  a  bone  has  been  removed. 

(a)  There  are  two  chief  plans  to  promote  healing  of  a  cavity  in  bone  : 

(1)  The  first  is  to  "  paper  "  the  inside  either  by  turning  a  flap  of  skin 
raw  surface  inwards  into  the  cavity,  which  must  be  clean  and  freshened  by 
scraping  out  granulations  :  very  similar  to  this  is  the  method  of  placing  a 
skin-graft  in  the  freshened  cavity,  pressed  firmly  into  place  with  a  plug  of 
gauze.  The  latter  plan  has  chiefly  been  used  for  producing  more  rapid 
healing  after  operations  on  the  mastoid  antrum,  but  may  also  be  useful  in 
the  long  bones. 

(2)  The  other  plan  is  by  the  use  of  bone  "  stopping  "  or  "  filling  "  ;  this 
is  somewhat  analogous  to  the  stopping  of  teeth,  except  that  the  "  stopping  " 
is  gradually  invaded  by  cells  and  replaced  by  new  bone. 

For  the  stopping  some  aseptic  material  is  employed  which  is  solid  at 
body-heat  but  melts  at  a  slightly  higher  temperature.  Solid  paraffin  of 
low  melting-point  or,  better,  sterile  mutton-fat  seems  as  good  as  anything 
else.  The  cavity  should  be  rendered  smooth  inside  and  all  infective  material 
removed,  then  well  dried,  and  disinfected  with  pure  carbolic  or  biniodide 
and  spirit.  Drying  with  hot  air  seems  hardly  necessary,  for  if  the  cavity 
he  well  dried  and  plugged  for  a  fewT  minutes  and  the  molten  stopping  run 
in,  just  as  it  is  on  the  point  of  solidifying,  it  will  set  at  once  and  securely 
prevent  any  exudation  from  the  wall  of  the  cavity.  The  periosteum  is 
sutured  over  the  stopping  and  the  wound  closed  without  drainage.  Asepsis 
is  a  sine  qua  non  for  this  operation,  and  it  is  therefore  more  successful  after 
removal  of  cysts  and  myeloid  sarcomas  than  in  the  treatment  of  chronic 
abscesses,  where  absolute  asepsis  is  always  doubtful. 

Decalcified  bone-chips  or  even  chips  of  living  bone  have  been  used  to 
fill  cavities  with  a  fair  amount  of  success. 

(b)  Bone-grafting.  This  is  needed  where  the  whole  thickness  of  a 
bone  has  been  removed. 

New  bone  can  be  formed  from  bone  itself  or  from  the  deeper  layer  of 
the  periosteum  (this  is  regarded  by  some  as  the  superficial  layer  of  the  bone). 
The  periosteum  has  also  the  function  of  controlling  the  growth  of  bone 
and  prevents  osseous  tissue  from  spreading  beyond  the  limits  of  this  mem- 
brane.    Mace  wen  advises  division  of  bone  for  grafting  into  small  pieces, 


\  TEXTBOOK  OF  SURGERY 

to  allow  free  egress  of  the  osteoblasts  from  the  bone,  and  maintains  thai  such 
grafts  actually  Lri<>\\.  while  Murphy  maintains  thai  the  grafts  only  acl  as 
a  scaffold  on  which  hone  grows  inwards  from  the  remains  of  the  original 
huiic.  Bone  for  grafts  may  he  taken  from  the  tibia  in  the  form  <>t  a  slice 
along  the  subcutaneous  border  or  a  large  piece  of  the  fibula  may  he  removed 
subperiosteal^,  or  ribs  may  he  employed.  In  any  case  it  seems  hot  to 
strip  the  hone  Ik. in  its  periosteum  and  apply  bone-grafts  devoid  of  this 
limiting  membrane  to  secure  wide  growth  of  the  grafts.  The  grafts  should 
lie  in  good  apposition  with  the  ends  of  the  bone  to  he  joined. 

The  most  careful  asepsis  is  needed  in  these  operations:  any  suppuration 
will  usually  lead  to  failure.  As  regards  dividing  the  grafts,  we  find  that 
considerable  fragments  "  take  "  quite  well  and  instances  of  large  masses  of 
hones  are  reported  as  having  been  successfully  transplanted  from  cadavers, 
so  that  much  division  of  grafts  seems  an  unnecessary  refinement. 

AFFECTIONS  OF  JOINTS 

The  joints  considered  here  are  the  diarthroses,  which  consist  of  the 
cancellous  ends  of  two  or  more  hones  covered  by  articular  cartilage,  united 
by  a  capsule  of  fibrous  tissue  ;  the  latter  is  strengthened  in  parts  by  liga- 
ments or  muscular  attachments,  lined  with  serous  synovial  membrane, 
raised  in  parts  into  folds  or  fringes  in  which  cartilage  is  often  present. 
and  which  covers  pads  of  fat  filling  in  the  depressions  existing  between 
the  ends  of  the  bones.  In  some  joints,  in  addition  to  the  articular  cartilage, 
there  are  interarticular  fibro-cartilages.  The  epiphyseal  line  may  he  outside 
the  joint-cavity  or  entirely  inside  it.  and  thus  affections  of  the  former  region 
lead  to  consecutive  disease  in  joints  of  this  construction.  The  bones. 
capsule,  ami  synovial  membrane  are  very  vascular,  while  the1  cartilage  is 
quite  avascular.  The  sacro-iliac  joint  is  included  in  this  study,  for  although 
movement  here  is  minimal,  it  possesses  a  synovial  membrane  and  is  liable 
to  the  same  diseases  as  the  movable  joints. 

(General  Considkhatioxs.     As  might  be  imagined  from  their  structure, 

disease  of  joints  in  many  instances  is  at  the  outsel  really  disease  of  the  1 s 

entering  into  their  composition,  which  later  spreads  to  the  joint  proper, 
and  the  more  characteristic  signs  arise  Erom  alteration  in  the  functions 
o|  tie'  joint  :  such  may  reasonably  be  regarded  as  cases  of  joint  disease. 
Iii  other  instances  the  disease  originates  in  structures  proper  to  the  joint, 
Mich  as  capsule,  synovial  membrane,  or  articular  cartilage. 

Affections  of  joints  are  almost  always  inflammations  and  degenerations 
partaking  of  the  nature  of  inflammations,  e.g.  neuropathic  diseases.  New- 
growths  of  joints  are  quite  imcommon,  though  occasionally  sarcoma  or 
endothelioma  of  the  synovial  membrane  is  found. 

The  following  terms  an-  used  to  denote  affection  of  various  part.-  of 
joint-.  Synovitis  implies  inflammation  of  the  synovial  membrane  only, 
usually  with  effusion  into  the  joint,  sometimes  with  thickening  of  the 
membrane.  If  tie'  other  structures  of  the  joint  are  involved  the  term 
arthritis   is  applied-    affection  and  erosion  of  the  cartilage  being   shown 


EXAMINATION  OF  JOINTS  391 

by  starting  pains  at  night ;  affection  of  the  capsule  and  ligaments  by 
displacement  of  the  ends  of  the  bone,  such  as  posterior  displacement  of  the 
knee-joint  or  lateral  mobility  of  this  joint  in  arthritis.  The  movements  of 
affected  joints  are  impaired  to  a  varying  degree  from  muscular  spasm  and 
changes  in  the  joint  itself,  according  to  the  severity  of  the  inflammation. 
Later,  as  inflammation  subsides  the  functions  of  the  joint  may  be  restored 
or  the  stiffness  may  persist,  and  if  severe  is  described  as  "  ankylosis,"  the 
varieties  of  which  are  described  later.  In  other  instances  the  inflammation 
may  spread,  breaking  through  surrounding  tissues,  and  open  on  the  surface, 
leaving  sinuses  which  communicate  with  the  joint  or  its  constituent  bones. 

Examination  of  Joints.  The  function  of  the  joint  should  be  noted  by 
getting  the  patient  to  use  the  limb  if  this  is  not  too  painful,  e.g.  by  walking  : 
in  some  cases  the  diagnosis  can  be  made  almost  at  once,  e.g.  congenital 
dislocation  of  the  hip. 

Next  the  movement  of  the  joint  should  be  tested  by  making  passive 
movements  and  comparing  these  with  those  of  the  healthy  side,  taking 
care  that  the  movement  really  is  at  the  joint  investigated  (impaired  move- 
ments of  the  hip  or  shoulder-joint  are  replaced  to  some  degree  by  movement 
of  the  scapula  on  the  trunk  or  the  pelvis  on  the  spine  :  methods  to  avoid 
these  pitfalls  are  mentioned  in  discussing  affections  of  these  joints). 

The  joint  is  then  examined  for  tenderness,  swelling,  fluctuation,  dis- 
placement of  the  bones  or  enlargement  of  these,  abnormal  mobility,  grating, 
fixity,  or  abnormal  position.  The  nature  of  an  inflammation  is  investigated 
by  examining  the  patient  or  his  own  or  family  history  for  evidence  of 
tubercle,  syphilis,  rheumatism,  haemophilia,  gout,  gonorrhoea,  injury, 
nervous  disease,  &c.  Sinuses  should  be  investigated  with  the  probe  or, 
better  still,  by  injection  with  30  per  cent,  of  bismuth-paste,  followed  by 
radiographs  of  the  opaque  injection  mass.  In  some  cases  the  joint  should 
be  aspirated  and  the  fluid  examined  bacteriologically. 

GENERAL   ANATOMICAL   ACCOUNT  OF  JOINT   AFFECTIONS 

The  anatomical  division  of  affections  of  joints  into  synovitis  and  arthritis 
is  useful  for  descriptive  purposes,  remembering  that  the  disease  may  progress 
from  the  synovial  membrane  to  the  rest  of  the  joint.  In  a  later  section 
affections  of  joints  will  be  considered  according  to  their  causes.  Both 
synovitis  and  arthritis  occur  in  varying  degrees  of  severity,  described  as 
acute,  subacute,  and  chronic. 

Acute  Synovitis.  The  causes  of  this  condition  are  crushes,  bruises, 
twists,  infection  from  punctures,  wounds  (this  will  more  often  cause  an 
arthritis),  rheumatism,  gonorrhceal  metastatic  infection,  and  very  rarely 
tubercle  or  syphilis. 

Anatomy.  The  synovial  membrane  is  congested,  red,  and  pours  a  copious 
exudation  into  the  joint-cavity,  rich  in  fibrin  and  likely  to  coagulate  :  in 
very  acute  conditions  there  may  be  considerable  haemorrhage  from  the 
acutely  congested  synovial  membrane  into  the  joint.  The  exudation  into 
the  joint  is  viscid  from  the  presence  of  synovia  and  turbid  from  emigration 


A  TEXTBOOK  OF  SURGERY 

of   leucocytes,    in   some   cases   definitely  purulent,   as  in    pysemic   joints 

and  infected  punctured  wounds  (in  some  instances  these  conditions  are 
to  be  regarded  as  synovitis  and  not  arthritis,  since  resolution  of  effusion 
and  restoration  of  function  may  occur  without  any  evidence  of  affection 
of  bone,  capsule,  or  cartilage). 

I;,  suits.  In  the  Blighter  cases,  especially  when  due  to  trauma  or  rheuma- 
tism, sometimes  in  gonorrhoea!  cases,  complete  resolution  takes  place  with 
absorption  of  the  effusion  and  return  of  the  congested  synovial  membrane 
to  the  normal  state.  Adhesions  may  form  inside  the  joint  from  organization 
of  the  fibrinous  exudate:  these  are  usually  slight  and  do  not  intervene 
between  the  cartilage-covered  surfaces  of  the  bones.  If  neglected  the  effu- 
sion may  persisl  and  cause  alterations  in  the  synovial  membrane;  absorp- 
tion becomes  difficult,  the  case  passing  into  one  of  "  chronic  synovitis."  In 
other  cases,  especially  in  the  infective  varieties,  the  process  may  be  pro- 
gressive and  invade  the  cartilages,  ligaments  and  hone,  becoming  a  condition 
of  arthritis.  This  happens  in  many  cases  of  infected  punctured  wounds, 
also  in  gonorrheal  and  pyaemic  joints. 

Signs,  There  is  swelling  about  the  joint,  mapping  out  the  synovial 
membrane  distended  by  the  effusion.  Heat,  redness,  and  fluctuation  will 
be  marked  in  superficial  joints  ;  pain  is  not  great  but  tenderness  is  marked  ; 
fever  is  only  present  in  the  suppurative  and  rheumatic  cases,  and  becomes 
much  more  marked  if  the  condition  is  progressing  to  arthritis. 

Treatment.  In  simple  cases  rest  on  a  splint  with  elastic  pressure  over 
the  joint  by  strapping  or  bandaging  over  wool  for  a  few  days,  followed  by 
ma— age  and  active  and  passive  movements,  will  cure  the  slighter  con- 
ditions;   if  these  pass  into  the  chronic  type  the  treatment  is  discussed 

late!'. 

In  suppurative  conditions,  as  indicated  by  greater  heat,  pain  and  tender- 
ness of  the  joint,  high  and  irregular  fever,  the  joints  should  be  opened  and 
washed  out  with  dilute  solution  of  biniodide  of  mercury,  drained  a  few  days 
till  the  exudate  becomes  non-purulent,  after  which  the  wound  may  be 
allowed  to  heal  and  massage,  &c,  employed. 

Subacute  and  Chronic  Synovitis  (Hydrops  articuli).  There  are 
several  causes  of  this  condition,  which  in  many  instances  is  not  far  removed 
from  and  readily  passes  on  into  some  variety  of  arthritis.  Chronic  syno- 
vitis often  results  as  a  sequel  to  the  acute  condition,  especially  of  traumatic 
origin,  and  usually  implies  that  there  is  more  damage  than  mere  synovitis, 
such  as  a  displaced  cartilage  or  injury  to  synovial  fringes — often  with 
production  of  cartilaginous  growths  in  the  latter,  leading  to  formation  of 
loose  bodies  in  the  joint;  or  it  may  be  that  rheumatoid  or  osteo-arthritic 
changes  are  developing  in  the  joint  and  that  it  is  passing  out  of  the  class 
synovitis  into  that  of  arthritis.  Congenital  and  secondary  accpiired  syphilis 
sometimes  cause  symmetrical  synovitis  with  large  effusion,  especially  into 
t  lie  knee-.  The  tubercle  bacillus  produces  synovitis  with  effusion  more  often 
in  adults  than  children,  and  in  some  cases  gonorrhoea  is  the  prime  source 
of  the  disease. 


ARTHRITIS  393 

Clinical  features.  Chronic  synovitis  may  be  evidenced  chiefly  by  con- 
siderable painless  effusion  into  the  joint  (Hydrops  articuli),  which  is  charac- 
teristic of  traumatic  synovitis,  congenital  syphilis,  and  sometimes  tubercu- 
losis of  the  joint,  but  is  also  found  in  conditions  where  there  is  more  than 
mere  synovitis,  as  in  osteo-arthritis  and  neuropathic  conditions.  In  other 
instances  the  synovial  membrane  may  be  thickened  and  fibrous,  as  is  the 
case  in  tuberculous  synovitis  and  that  due  to  gonorrhoea!  infection  and 
tertiary  syphilis,  in  which  gummatous  synovitis  is  not  uncommon.  All 
the  above  conditions  except  the  last  are  prone  to  pass  on  into  an  arthritis. 

Diagnosis.  This  consists  in  finding  distension  of  the  synovial  cavity 
with  fluid,  or  thickening  of  the  membrane  of  a  chronic  nature  without  heat, 
redness,  or  much  pain,  with  no  grating  on  moving  the  joint  or  starting 
pains  at  night  from  erosion  of  cartilage,  nor  alteration  of  the  bones  as  found 
by  palpation  or  radiographs. 

Treatment.  If  due  to  specific  disease  the  treatment  is  discussed  later. 
The  usual  type  which  follows  injury  and  is  closely  allied  to  traumatic  osteo- 
arthritis, of  which  it  may  be  the  initial  stage,  is  treated  by  application  of 
elastic  pressure  to  reduce  the  fluid  and  graduated  massage  and  exercises 
to  strengthen  the  weakened  muscles  and  ligaments.  Hot-air  baths  relieve 
pain  if  present.  If  the  condition  resists  the  above  treatment  for  some 
months  there  is  probably  some  loose  cartilage  or  chondrified  synovial  fringe 
present  in  the  joint  and  exploration  is  advisable  :  in  any  case  evacuation  of 
fluid  and  washing  out  the  joint  with  saline  or  dilute  biniodide  of  mercury 
solution  may  do  good. 

Artheitis.  Affections  of  the  whole  joint  may  start  in  the  synovial 
membrane,  as  has  been  mentioned,  or  in  the  ends  of  the  adjacent  bones  ; 
or  may  attack  the  whole  joint  at  once  so  that  no  particular  place  of  origin 
can  be  ascertained.  According  to  their  severity  we  may  divide  these 
affections  into  acute,  subacute,  and  chronic  ;  a  further  distinction  into 
suppurative  and  non-suppurative  may  be  made,  and  it  will  be  found  that 
chronic  arthritis  is  seldom  suppurative  while  acute  arthritis  is  frequently 
of  this  nature. 

Acute  Arthritis  may  arise  in  the  following  ways  : 

(1)  Infection  of  joints  with  pyogenic  organisms  from  penetrating  wounds 
will  cause  a  synovitis  which,  if  the  organism  be  virulent  or  the  condition 
neglected,  will  rapidly  pass  on  to  become  an  arthritis  (with  surgical  care 
many  such  infections  do  not  pass  beyond  the  synovial  membrane). 

(2)  By  infection  from  some  neighbouring  part,  e.g.  the  spread  of  an 
acute  diaphysitis,  where  the  epiphyseal  line  is  inside  the  joint,  as  in  the 
hip.  less  often  by  passing  through  the  epiphysis.  An  inflamed  bursa  is 
another  common  source  of  infection,  e.g.  prepatellar  bursitis  leading  to 
acute  arthritis  of  the  knee. 

(3)  Blood-borne  infections,  where  there  are  pathogenic  organisms  circu- 
lating in  the  blood  and  some  slight  injury,  predisposes  to  a  settlement  in 
the  joint  (in  a  similar  manner  to  the  onset  of  acute  diaphysitis). 

(4)  Another  variety  of  blood-borne  infection  is  where  there  is  some 


A  TEXTBOOK  OF  SURGERY 

ic  infection  such  as  enteric,  scarlatina,  pyogenic  pyaemia  (often 

originating  in  acute  diaphysitis),  | umonia,  gonorrhoea,  and  in  this  group 

must  be  included  acute  rheumatism. 

(5)  The  deposit   of  irritating  chemical  products  of  unorganized  nature 

is  instanced  by  the  deposit  of  uric  acid  in  joints,  known  as  gout. 

In  the  firsl  three  groups  the  arthritis  is  nearly  always  suppurative;  in 
the  las!  group  suppuration  never  occurs:  while  amongsl  the  blood-borne 
infections  the  pyaemic  type   Buppuration   is  frequent  but  in  some 

instances,  as  enteric  and  gonorrhoea,  is  unusual. 

lomy.  The  congested  and  inflamed  synovial  membrane  becomes 
permeated  with  and  convened  into  granulation  tissue;  the  capsule  and 
ligaments  soon  follow  suit  and  become  softened,  giving  way  and  allowing 
abnormal  displacement  even  to  the  extent  of  dislocation  to  occur  (patho- 
logical dislocation).  The  cartilage  loses  its  translucent  appearance  and 
nes  dull  and  soon  eroded,  exposing  bare  hone  beneath,  which  soon 
becomes  the  seat  of  acute  osteitis  ;  the  synovial  cavity  becomes  filled  with 
pus  and  broken-down  fragments  of  cartilage  and  hone  debris.  The  resulting 
abscess,  unless  opened,  tracks  to  the  surface  and  ultimately  bursts,  unless  the 
patient  succumbs  first  to  the  virulence  of  the  infection  and  toxaemia.  Later 
the  eroded  cartilage  and  inflamed  ends  of  the  hones  are  replaced  by  granulation 
tissue,  and  healing  at  length  takes  place  with  obliteration  of  the  joint-cavity 
and  fibrous  ankylosis,  which  becomes  bony  if  the  granulation-tissue  ossifies. 

Diagnosis.  From  the  less  severe  condition  of  acute  synovitis  the  diag- 
is  made  partly  on  the  general  condition,  the  fever  being  much  higher 
and  rigors  not  infrequent  ;  the  constitutional  depression  is  greater.  Locally 
the  joint  is  very  t  ender  and  if  superficial  the  skin  will  be  red  or  even  purplish 
in  severe  infections.  In  the  early  stage  abnormal  mobility,  from  softening 
of  ligaments  and  starting-paii  s  at  night,  will  not  have  had  time  to  occur 
and  in  the  very  acute  cases  it  is  most  important  to  open  and  drain  the 
joint  early.  Therefore  in  joint  affections  where  the  constitutional  signs 
are  severe  the  joint  should  be  aspirated,  and  if  pus  and  organisms  be 
found  the  joint  should  be  opened  and  drained  without  delay.  As  the 
condition  advances  the  displacement  or  dislocation  of  the  bones,  formation 
of  si  renders  diagnosis  easy.     Under  certain  conditions,  however, 

acute  arthritis  comes  on  without  any  great  constitutional  disturbance. 
Thus  in  gonorrhoeal  infection  of  joints  the  fever  is  not  great  and  the  swelling 
of  the  peri-articular  tissues  moderate  in  many  cases,  but  the  pain  often 
intense.  We  cannot  in  Buch  cases  on  physical  signs  alone  say  that  arthritis 
is  present,  but  we  know  from  experience  that  disorganization  of  the  joint 
and  subsequent  ankylosis  is  by  no  moans  uncommon.  Again,  where  the 
ral  condition  ol  the  patient  is  grave,  as  in  enteric,  the  joint  affection 
may  escape  notice,  and  dislocation  of  the  hip  from  arthritis  is  often  not 
discovered  in  these  patients  till  convalescence  is  taking  place. 

In  '_rout.  again,  the  local  appearance  is  that  of  ultra-acute  inflammation, 
yet  the  constitutional  signs  are  but  slight  and  the  joint  recovers  well  from 
the  I  the  disease. 


CHRONIC  ARTHRITIS  395 

Subacute  Arthritis.  These  affections  are  usually  due  to  blood-borne 
infections,  the  commonest  being  the  tubercle  bacillus  and  the  gonococcus  ; 
sometimes  pyogenic  organisms  may  cause  subacute  changes. 

The  changes  in  the  joint  are  like  those  of  acute  inflammation,  but  advancs 
less  rapidly  and  are  less  urgent.  The  synovial  membrane  and  ligaments 
soften  and  form  granulation-tissue  ;  the  cartilage  is  eroded ;  abscess- 
formation  is  common  in  the  synovial  cavity  and  carious  ends  of  the  bones 
involved.  There  is,  however,  more  tendency  to  repair  by  production  of 
fibrous  tissue  and  less  pain  and  hypsemia  of  the  part.  The  joint  appears 
swollen  and  puffy,  movements  are  greatly  impaired — the  doughy,  ovoid 
swelling  about  the  joint  forming  a  marked  contrast  to  the  shrunken  limb 
above  and  below,  the  muscles  of  which  are  wasted  from  disuse.  The  puffy 
appearance  of  the  joint  forms  the  "white  swelling"  of  older  pathology,  so 
characteristic  of  tuberculosis.  The  general  condition  is  unaffected  at  first 
until  sinuses  form  and  secondary  infections  of  these  occur,  causing  irregular 
hectic  fever,  wasting,  lardaceous  disease,  &c.  In  many  instances  there  is 
little  tendency  to  suppuration  and  fibrous  or  bony  ankylosis  readily  results, 
while  in  other  cases  the  process  spreads  to  the  bones  as  subacute  osteo- 
myelitis (especially  in  tuberculosis),  and  large  portions  of  bone  are  destroyed 
by  caries. 

Chronic  Arthritis.  Under  this  heading  we  include  the  more  chronic 
forms  of  tuberculosis  and  tertiary  syphilis,  but  chiefly  the  affections  which 
may  be  described  as  rheumatoid,  and  amongst  which  are  included  such 
different  conditions  as  traumatic  osteo-arthritis,  neuropathic  joints,  gout, 
hemophilic  joints,  &c.  In  these  cases  the  process  is  usually  slow  except 
in  some  neuropathic  joints.  There  is  fibrillation  and  erosion  of  cartilage, 
rarefying  and  sclerosing  changes  in  the  bones,  which  may  be  greatly  enlarged 
at  their  ends  and  form  outgrowths  known  as  osteophytes ;  the  capsule  may 
be  thickened,  producing  fixity,  or  softened,  causing  abnormal  mobility  of 
the  joint.  The  synovial  membrane  often  undergoes  hypertrophy  into 
villous  outgrowths  or  fringes  which  contain  cartilaginous  and  calcified  bodies, 
and  these  last  may  greatly  interfere  with  the  function  of  a  joint. 

All  the  above  conditions  will  be  further  considered  and  their  treatment 
discussed  in  the  section  on  the  Special  Forms  of  Arthritis. 

Results,   Sequela?,   and   Complications   of  Arthritis   and   Synovitis. 

(I)  Ankylosis.  Mention  has  been  made  already  of  this  termination  of 
inflammation  in  joints.  By  this  term  is  meant  a  stiffness  or  loss  of 
mobility,  more  or  less  complete,  of  the  joint.  Where  such  stiffness  is  due 
to  altered  condition  of  the  joint  itself  it  is  called  true  ankylosis,  where 
caused  by  affections  outside  the  joint  the  term  false  or  spurious  ankylosis 
is  employed.  In  practice  the  term  ankylosis  is  seldom  applied  to  stiffness 
of  a  joint  unless  arising  in  some  part  of  the  joint. 

Spurious  ankylosis  may  be  due  to  all  manner  of  things  affecting  the 
movement  of  joints,  such  as  cicatricial  contraction  of  the  skin,  contraction 
of  muscle,  ossification  of  muscle,  adhesions  of  tendons,  &c. 

True  ankylosis  may  be  fibrous  or  bony. 


\  TEXTBOOK  OF  SURGERY 


(1) 
in  the 
bra  no 


Fibrous  ankylosis  may  result  from  synovitis;    fibrous  bands  form 
joint  ami  then1  are  thickening  and  contraction  of  the  synovial  mem- 

:    such  ankylosis  can  usually  be  much  improved  by  massage,  active 

and    passive    move- 
ments. 

Where,  in  a  case 
of  arthritis  the  arti- 
cular cartilages  are 
destroyed,  more  com- 
plete ankylosis  will 
occur,  the  bones  being 
fixed  together  by 
dense  bands  of  fibrous 
tissue.  In  such  case 
some  movement  is  al- 
ways possible,  though 
where  the  constrain- 
ing bands  are  dense 
and  short  this  may 
be  difficult  to  detect. 
Practically  any  in- 
flammatory affection 
of  joints  may  lead  to 
ankylosis  if  the  car- 
tilage be  eroded,  but 
this  termination  is 
more  usual  in  the 
acute  and  subacute 
varieties,  especially 
from  pyogenic  or  tu- 
berculous infections. 
(2)  Bony  ankylo- 

i'i,     n.-'   (ii       , .i   ;*•    ci    i  ,i  i      ,•  sis  mav  result   from 

i  to.  iw.  Usteo-arthritis  of  the  knee-joint  (skiagram),  snowing  >7  _ 

well-marked  osteophytes  of  the  lower  end  of  the  femurand  ossification  of  the 
patella-  fibrous   tissue    be- 

tween the  ends  of  the  bones  when  denuded  of  cartilage,  or  in  the  chronic 
varieties  from  interlocking  of  osteophytes  or  ossification  of  ligaments,  e.g. 
in  old-standing  scoliosis  and  osteo-arthrif  is. 

Ankylosis  is  a  natural  means  of  cure  of  severe  joint-disease  when  there 
i-  erosion  of  cartilage  ;  and  the  surgeon's  aim  is  to  maintain  the  bones  in 
the  best  position,  e.g.  in  the  case  of  the  hip  adduction  and  flexion  are  to  be 
avoided. 

Diagnosis,  in  testing  lor  movement  of  a  joint  care  must  be  taken  to 
fix  one  of  the  bones  completely  before  trying  to  move  the  other.  If  bony 
ankylosis  is  present  the  joint  is  quite  immobile  and  there  is  no  pain  caused 
by  attempt,  ;,t  moving  it.     Tn  cases  of  fibrous  ankylosis  varying  amounts 


TREATMENT  OF  ANKYLOSIS  397 

of  movement  are  possible  which  do  not  cause  pain  unless  considerable  force 
be  used,  if  the  condition  is  healed ;  but  if  the  inflammatory  process  is  still 
active,  pain  will  be  elicited.  Examination  under  anaesthesia  and  radiographs 
will  be  of  assistance  in  doubtful  cases. 

Treatment.  In  most  cases  this  natural  process  of  cure  is  best  left  to 
pursue  its  course  if  the  bones  are  in  a  useful  position — e.g.  the  hip  slightly 
abducted  and  almost  extended,  the  knee  almost  extended,  the  elbow  flexed 
to  rather  less  than  a  right  angle,  &c. 

Attempts  to  improve  the  position  by  violent  wrenching  are  to  be  avoided 
while  the  disease  is  active  as  likely  to  set  up  renewed  inflammation  and 
even  dissemination  ;  thus  miliary  tuberculosis  is  recorded  to  have  been 
set  up  by  wrenching  a  tuberculous  hip  or  knee.  The  position  of  the  bones 
may  be  improved  while  the  condition  is  active  or  when  fibrous  ankylosis 
is  present  by  various  splints  and  modes  of  extension.  When  the  position 
of  the  joint  is  bad,  after  the  disease  has  healed  attempts  should  be  made  to 
improve  this  :  there  are  two  main  plans  of  attaining  this  result  :  (1)  osteo- 
tomy, (2)  excision  and  arthroplasty. 

(1)  If  osteotomy  is  performed  the  limb  is  restored  to  good  position  by 
dividing  the  bone  either  at  or  close  to  the  joint  without  attempting  to 
restore  the  function  of  the  joint,  which  is  left  ankylosed,  and  such  treatment 
is  as  a  rule  advisable  in  affection  of  the  joints  of  the  lower  limb,  since  a  firm 
but  stiff  leg  is  more  useful  than  one  which  is  movable  but  weak  and  flail- 
like. 

The  method  of  straightening  the  limb  depends  on  the  joint  affected  ; 
thus  in  the  case  of  the  hip  it  is  better  to  divide  the  bone  just  below  or  between 
the  trochanters  rather  than  to  excise  the  joint,  as  being  easier  and  more 
likely  to  give  a  firm  leg.  In  the  case  of  the  Hexed,  ankylosed  knee,  cunei- 
form osteotomy  or  excision  of  the  joint  is  advisable. 

(2)  Excision.  The  matter  is  different  in  the  upper  limb,  where  a  movable 
joint  is  more  useful  than  one  which  is  stiff,  even  if  the  mobile  joint  is  not 
very  strong.  The  shoulder  and  wrist  seldom  need  to  be  interfered  with 
for  this  reason,  but  the  elbow  may  often  be  excised  with  advantage,  and 
for  choice  after  growth  is  finished  unless  the  prolonged  fixity  of  the  joint  is 
causing  great  atrophy  of  the  muscles  which  move  it. 

Arthroplasty.  Of  late  attempts  have  been  made  to  make  movable  joints 
in  cases  of  ankylosis,  with  certainty  and  precision,  and  in  the  hands  of  certain 
surgeons  (Murphy)  excellent  results  are  recorded  in  many  instances.  Thus  in 
the  hip,  if  both  are  ankylosed,  the  impaiiment  of  progression  is  extreme  and 
an  attempt  should  be  made  to  obtain  at  least  one  mobile  joint,  mere  excision 
being  useless.  The  acetabulum  is  gouged  out,  a  new  head  fashioned  to  the 
femur,  and  ankylosis  prevented  by  inserting  a  flap  of  fascia  lata  between 
the  ends  of  the  bones  :  similar  operations  are  suitable  for  the  shoulder 
and  elbow  ;  for  the  knee  it  cannot  often  be  recommended. 

(II)  Loose  Bodies  in  Joints.  In  the  course  of  inflammations  and  degenera- 
tions of  joints  there  arise  loose  bodies  of  varying  structure  and  size,  which 
may  be  quite  free  or  tethered  by  a  leash  of  synovial  membrane.     Most  of 


\  TEXTBOOK  OF  SURGERY 


these  loose  bodies  take  origin  in  the  Synovial  fringes  inside  the  joint 
follows  : 

(a)  From  overgrowth  <>t'  the  cartilage  cells  normally  present    in   the 
fringes,  which  may  become  calcified  or  ossified. 

(I>)  Prom  organization  of  haemorrhages  into  the  fringes,  whether  trau- 
matic <>i  inflammatory  in  origin. 

(c)  As  t  he  ion  It  of  repeated  trauma,  the  enlarged  fringes  being  repeatedly 
nipped  between  the  ends  of  the  bones  and  inflammation  being  thus  caused. 

(d)  A  development  of  a  large  number  of  fat-nodules  in  the  synovial 
fringes   causes   them    to   assume   a   cauliflower  appearance  and  is  known 

as  lipoma  arborescens, 
which  may  become  os- 
sified. 

Other  sources  of 
origin  of  loose  bodies 
are  : 

(a)  Separation  of 
articular  cartilage  from 
trauma  or  inflamma- 
tion ;  (b)  osteophytes 
may  become  separated; 
(c)  quiet  necrosis  may 
detach  small  portions  of 
bone  ;  (d)  melon-seed 
bodies  arising  from  the 
organization  of  blood 
or  lymph  may  form, 
though    less    often    than    in    tendon-sheaths    and   bursa?. 

Signs.  These  bodies  may  cause  no  trouble  till  they  have  been  present 
a  considerable  time.  They  may  be  noted  by  the  patient,  sliding  about 
the  joint,  popping  into  viewT  and  disappearing  again  with  a  furtive  rapidity 
well  meriting  the  term  "  joint-mouse  "  (Gelenk-maus).  In  other  instances 
they  may  become  caught  between  the  articular  surfaces  of  the  bone,  causing 
locking  and  great  pain  in  the  joint  not  easy  to  distinguish  from  affection 
of  the  semilunar  cartilages  of  the  knee,  in  which  joint  also  loose  bodies  are 
most  frequent.  Sometimes  the  loose  bodies  may  by  sheer  size  interfere  with 
movement  of  the  joint:  thus  we  found  in  one  case  two  large  loose  bodies  in  the 
Bupra-patellar  pouch  of  the  knee-joint  which  interfered  with  flexion  of  the  knee 
by  keeping  the  tendon  of  the  quadriceps  unpleasantly  stretched.  (Fig.  164.) 
Diagnosis  is  not  easy  unless  the  body  be  palpable  or  can  be  seen  in 
radiographs  when  it  happens  to  be  calcified.  There  is  not  the  characteristic 
history  of  trauma,  followed  at  once  by  locking,  noted  in  internal  derange- 
ment of  the  knee,  nor  is  there  the  tenderness  over  the  internal  semilunar 
'ii  tilage  at  the  upper  end  of  the  tibia. 

Treatment.     If  causing  t  rouble  these  bodies  may  be  removed  by  incision, 
with  all  aseptic  precautions,  on  one  side  of  the  patella ;    other  enlarged 


Fig.   164.     Loose  body  from  osteo  arthritic  knee-joint,  con- 
sisting of  hone  and  cartilage  (slightly  enlarged). 


BAKERS  CYSTS 


399 


synovial  fringes  should  be  looked  for  and  removed  if  found.  Removal  of 
loose  bodies  is  advisable,  as  the  movement  of  these  bodies  will  ultimately 
cause  erosion  of  cartilage  and 
set  up  chronic  inflammatory 
changes  in  the  joint. 

(Ill)  Bursal  Cysts  connected 
with  Joints  (Baker's  cysts). 
Cystic  swellings  connected  with 
joints  occasionally  arise  in 
apparently  healthy  joints,  as 
hernise  of  the  synovial  mem- 
brane. The  more  usual  condi- 
tion is  for  some  bursa  normally 
connected  with  a  joint  to  be- 
come distended  with  the  fluid 
formed  in  the  cavity  of  the 
joint  from  some  inflammatory 
or  degenerative  change,  such 
as  tubercle  or  osteo-arthritis. 
Thus  the  bursa  surrounding 
the  long  tendon  of  the  biceps 
at  the  shoulder  may  become 
distended  in  cases  of  affection 
of  the  shoulder-joint,  and  such 
bursal  swelling  may  track  and 
point  on  the  surface  at  some 
distance  from  the  joint  in  which 
it  originates.  The  fluid  from 
these  cysts  is  yellow,  of  gla in- 
consistency, often  containing 
curdy  material.  In  some  instances  such  cysts  become  cut  off  from  the 
joint  where  they  originate. 

Treatment.     If  causing  trouble  from  their  size  or  position  they  should 
be  removed  by  dissection. 


Fig.  165.     Calcified  synovial  fringes  in  the 
knee-joint  (skiagram). 


SPECIAL  INFLAMMATIONS  AND  DEGENERATIONS 
OF  JOINTS 

The  following  provisional  classification  may  be  found  useful  : 

(I)  Acute  infections,  including  pyogenic  and  urethral  infections,  exan- 
themata, pneumonia,  rheumatism,  &c. 

(II)  Inflammations  due  to  a  chemical  irritant  constitutionally  produced  ; 
gout. 

(III)  Infective  conditions  of  subacute  and  chronic  nature  :    tubercle  and 
syphilis. 

(IV)  The  Rheumatoid  Affections.    These  are  grouped  together  on  account 
of  their  anatomical  resemblance  to  each  other  without  respect  of  the  causal 


100  A  TEXTBOOK  OF  SURGERl 

agents,  which  are  in  many  instances  still  obscure  ;  various  types  oi  osteo- 
arthritis, neuropathic  and  hemophilic  joints. 

(V)  /    i   tional  I '  w  as(  oj  Joints. 

-  eral  of  the  above  conditions  are  of  medical  rather  than  surgical 
interest  and  will  be  dismissed  Bhortly,  only  referring  to  points  of  difficulty 
in  diagnosis  or  where  surgical  treatment  is  likely  to  be  needed. 

(1)  Acute  Infections  of  Joints,  (a)  Pyogenic  Infections.  Theorgan- 
isms  found  in  these  conditions  are  the  staphylococcus  aureus,  the  strepto- 
coccus, ami  the  pneumococcus,  which  obtain  entry  to  the  joint  through 
punctured  wounds,  by  spread  from  neighbouring  parts  or  by  blood-borne 
infection  from  obvious  or  hidden  primary  foci,  such  as  inflammations  of 
tonsils,  boils,  &c.  These  are  the  conditions  usually  described  as  acute 
suppurative  arthritis,  but  pyogenic  organisms  are  also  responsible  for  affec- 
tions of  joints  arising  in  general  infective  diseases  such  as  scarlatina,  enteric, 
&C,  in  each  of  which  conditions  there  are  some  clinical  differences  worth 
special  description. 

Where  the  infection  originates  from  injury,  punctured  wound,  or  meta- 
stasis from  distant  and  often  obscure  focus,  e.g.  boils,  infected  scratches, 
nasal  suppuration,  tonsillar  infection,  &c,  the  condition  usually  begins 
as  suppurative  synovitis,  passing  shortly  into  an  arthritis.  When  starting 
liv  spread  from  surrounding  structures,  as  from  an  osteomyelitis,  the  condi- 
tion is  usually  one  of  suppurative  arthritis  from  the  first. 

Signs.     These  have  been  described  under  Acute  Arthritis  and  Synovitis. 

Treatment.  Early  operation  and  drainage  is  of  paramount  importance 
in  these  cases,  since  if  the  joint  is  attacked  while  the  infection  is  still  confined 
to  tin'  synovial  membrane  the  joint  may  be  saved  and  restored  to  its  normal 
condition.  Aspiration  of  suspicious  joints  should  be  practised,  and  if 
suppuration  is  taking  place  the  joint  freely  opened,  washed  out  with  mild 
antiseptic  lotion,  drained,  and  irrigated  daily  for  a  few  days.  Any 
source  of  infection,  whether  in  proximity,  as  diaphysitis,  or  remote,  as  boils, 
should  be  treated.  The  limb  should  be  immobilized  on  a  splint  in  the  best 
position  for  a  few  days  and  the  joint  washed  out  daily:  if  the  discharge 
shortly  becomes  serous  it  is  pretty  certain  that  the  suppuration  is  only 
synovial,  and  passive  movement  may  be  commenced  early  (in  about  a  week)  ; 
but  if  profuse  suppuration  persists  and  there  is  irregular  fever,  stalling 
pains  at  night  and  constitutional  depression,  the  condition  is  certainly  one 
of  arthritis  and  healing  will  only  take  place  by  ankylosis.  Therefor. •  in 
such  cases  the  splints  must  be  retained  till  healing  has  taken  place.     Some- 

ti s  further  operative  measures  to  promote  drainage,  such  as  excision  of 

the  carious  ends  of  the  bones,  must  be  practised  ;  for  severe  spreading 
infection  amputation  may  be  needed.      When  healing  is  complete  the  anky- 

losed  joint  may  be  left  or  treated  to  produce  better  function,  as  described 
under  Ankylosis  (p.  397). 

(I)  Scarlatinal  Affections  of  Joints.  These  usually  start  in  the  third 
week'  of  the  fever  ;    two  forms  are  described  : 

(a)  An    arthralgia     with    synovial    effusion    (scarlatinal    rheumatism) 


SPECIAL  FORMS  OF  ACUTE  ARTHRITIS 


401 


affecting  the  small  joints  of  the  hands  and  resembling  gonorrhoea!  infection 
of  these  joints. 

(b)  Pycemic  joints  of  streptococcal  origin  (usually  occurring  in  the  knee). 
This  form  has  a  bad  prognosis  indicating  a  severe  grade  of  infection,  and 
demands  urgent  sur- 
gical treatment,  free 
drainage,  excision,  &c. 
The  milder  rheumatic 
type  is  treated  like 
rheumatism  or  gonor- 
rhoeal  joints. 

(2)  Influenzal  In- 
fection. The  hip  is 
usually  affected,  the 
condition  being  one  of 
non- suppurative  effu- 
sion followed  by  fib- 
rous ankylosis. 

(3)  Pneumococcal 
Infections.  Suppura- 
tion of  a  joint  in  the 
course  of  pneumonia 
is  really  a  form  of 
pyaemic  joint  and  con- 
sequent on  a  general 
infection  with  the  or- 
ganism, the  prognosis 
being  therefore  corre- 
spondingly grave.  The 
joint  or  joints  swell  up 
often  without  much 
pain,  and  when  opened 
contain  thick,  creamy 
pus.  If  the  joint  be 
washed  out  there  is 
some  chance  of  its 
recovering  without  losing  its  functions,  but  more  often  ankylosis  ensues 
if  the  patient  survives. 

(4)  Joint  Affections  in  Enteric  Fever.  The  infection  may  be  with  typhoid 
bacilli  pure  or  mixed  with  pyogenic  cocci.  The  result  may  be  simple 
synovitis,  but  the  most  usual  condition  is  an  acute  arthritis  (especially  of 
the  hip-joint),  with  distension,  softening  of  the  capsule,  and  pathological 
dorsal  dislocation  of  the  head  of  the  femur.  This  is  likely  to  escape  notice, 
and  the  hips  should  be  examined  for  any  abnormality,  as  a  routine  in  nursing 
typhoid  patients. 

Treatment.     Where  there  is  a  large  effusion,  aspiration  of  the  joint  should 
t  26 


/ 


Fig.    16(i.      Skiagram  of  knee-joint  showing  osteo -arthritic 
changes  in  the  form  of  osteophytes,  due  to  enteric  fever  ten 
years  previously. 


102  A  TEXTBOOK  OF  SURGERY 

he  (lour,  otherwise  the  joint  is  simply  kepi  in  good  position  by  splints  or 
extension.  When'  the  infection  is  mixed  with  cocci  or  purely  coccal  the 
arthritis  is  more  likely  to  be  suppurative  with  wide  destruction  of  the  joint 
surfaces,  and  it  will  be  necessary  in  such  cases  to  open  and  drain  the  joint 
or  even  remove  bone,  draining  till  the  suppuration  subsides. 

(5)  Pycsmic  and  Puerperal  Injections  of  Joints.  These  are  varieties  of 
pyogenic  infection  occurring  in  the  course  of  generalized  infections  from 
bone  disease  (diaphysitis)  and  puerperal  infections  of  the  uterus.  In  any 
case  thf  infection  is  usually  a  pure  synovitis  at  first,  and  if  drained  early  the 
joints  may  recover. 

Painless  effusion  is  characteristic  of  pysemic  joints,  and  the  surgeon 
must  not  be  misled  by  the  apparently  mild  nature  of  the  disease  and  treat 
the  joint  on  too  conservative  lines.  Aspiration  should  be  done  at  once, 
and  if  the  effusion  is  pus  the  joint  should  be  opened,  washed  out  with  mild 
antiseptic  lotion,  and  drained  a  few  days.  With  early  massage  and  move- 
ment good  functional  results  can  fairly  often  be  obtained. 

((>)  Dysenteric  Infections.  The  knees  are  usually  affected  and  late  in  the 
course  of  the  disease.  The  condition  is  one  of  large  effusion  of  mildly 
suppurative  nature,  yielding  readily  to  aspiration  or  washing  out  the  joint. 

(7)  Acute  Rheumatism.  It  is  generally  admitted  that  rheumatic  joints 
are  part  of  a  general  infection,  as  evidenced  by  the  number  of  joints  affected 
and  the  occurrence  of  pericarditis,  endocarditis,  and  subcutaneous  nodules, 
which  form  a  picture  that  may  be  reasonably  compared  to  a  very  attenu- 
ated degree  of  pya?mia,  but  in  which  the  metastases  do  not  suppurate  owing 
to  the  mildness  of  the  infection.  The  causative  organism  has  not  yet  been 
agreed  upon  by  experts  ;  possibly  more  than  one  organism  may  be  respon- 
sible, especially  in  view  of  the  widely  different  course  which  the  disease  may 
take. 

The  disease  occurs  in  the  form  of  acute  s}7novitis  of  several  joints,  which 
generally  recover  completely,  the  affection  rapidly  appearing  in  one  joint 
as  it  subsides  in  another.  Very  rarely  do  disorganization  and  arthritis 
take  place  in  rheumatic  joints. 

The  main  importance  of  acute  rheumatism  in  surgery  lies  in  the  liability 
of  mistaking  it  for  acute  infections  of  bone  (diaphysitis)  and  with  gonorrhoeal 
joints  (q.v.). 

The  treatment  is  described  in  medical  works  :  surgical  measures  are 
seldom  needed.  But  if  the  affection  is  prolonged  measures  must  be  taken 
to  prevent  the  joints  from  assuming  bad  positions,  by  the  use  of  splints, 
extension,  massage,  &c. 

(8)  Gonorrheal  Infection  of  Joints,  Urethral  Infection.  In  most  cases 
the  cause  is  a  metastatic  infection  of  joints  with  gonococci  derived  from 
the  urethra  during  a  recent  attack  of  gonorrhoea  (seldom  before  the  third 
week)  or.  later,  dining  the  persistence  of  a  latent  or  obvious  gleet.  The 
infection  may  be  pure  or  of  gonococci  mixed  with  other  pyogenic  organisms. 
Less  frequently  affections  of  joints  arise  in  other  urethral  conditions,  as 
after  instrumentation  for  stricture  or  enlarged  prostate  or  alter  prostatec- 


GONORRHCEA  RHEUMATISM  403 

tomy.  In  some  instances  these  joint  infections  are  not  gonococcal  as  far 
as  can  be  ascertained,  but  it  must  be  remembered  that  the  gonococcus  dies 
out  readily  and  may  not  be  found  in  cultures  from  joints  although  present 
originally. 

Several  types  of  gonorrhoea!  rheumatism  are  described  : 

(1)  The  arthralgic  type,  which  is  a  mild  synovitis  with  very  little  effusion, 
causing  considerable  pain  in  the  affected  joints  but  usually  of  transient 
nature,  though  occasionally  passing  into  the  more  severe  types. 

(2)  A  synovitis  with  considerable  effusion — in  fact  a  hydrarthrosis — 
found  usually  in  the  knees,  coming  on  suddenly  with  malaise  and  moderate 
pyrexia. 

(3)  A  non-suppurative  arthritis  is  perhaps  the  most  usual  condition. 
The  periarticular  structures,  capsule,  and  ligaments  are  most  affected, 
there  being  but  little  effusion  into  the  joint.  A  similar  affection  of  fascial 
structures  apart  from  joints  is  common,  e.g.  the  plantar  fascia.  Any  of 
the  larger  joints — hip,  knee,  ankle,  shoulder,  elbow,  wrist —  may  be  affected 
as  well  as  the  small  joints  of  the  hand.  These  become  very  painful  and 
tender,  swollen  but  without  effusion,  and  in  severe  cases  red  as  well.  Pyrexia 
and  general  disturbance  are  slight.  Usually  several  joints  are  affected,  most 
of  which  recover  fairly  soon,  but  the  brunt  of  the  attack  is  usually  borne 
by  one  or  two  joints  which  resist  treatment  for  a  considerable  time  and 
may  be  severely  disorganized  and  finally  ankylose. 

(4)  A  subacute  suppurative  arthritis  occurs,  but  not  commonly.  This 
is  due  to  mixed  infection,  and  there  is  considerable  destruction  of  the  joint 
structures  with  formation  of  abscesses  and  subsequent  ankylosis. 

Diagnosis.  To  distinguish  from  acute  rheumatism  careful  investigation 
may  be  needed.  The  greater  persistence  of  this  form  of  arthritis,  its  peri- 
articular site,  its  extremely  painful  nature  and  resistance  to  salicylates, 
should  put  the  practitioner  on  his  guard  with  respect  to  a  case  labelled 
rheumatism,  and  examination  should  be  made  for  foci  of  gonorrhceal 
infection,  such  as  obvious  gonorrhoea  or  gleet,  latent  deep  urethritis  (pros- 
tatic massage,  the  two-glass  test,  &c.  ;  see  Urinary  Diagnosis),  vaginitis 
and  inflamed  appendages  in  women,  gonorrhceal  ophthalmia,  &c. 

The  sudden  appearance  of  a  tolerably  acute  arthritis  in  one  joint,  usually 
in  a  young  adult,  without  much  fever  or  general  disturbance — the  swelling 
being  not  only  in  the  joint  proper  but  spreading  above  and  below — in  the 
periarticular  tissues,  the  chronicity  and  the  greater  local  pain,  will  usually 
serve  to  distinguish  from  rheumatism. 

The  more  chronic  varieties  are  not  unlike  tuberculous  infections,  and 
gonorrhceal  infection  should  be  excluded  before  making  the  diagnosis  of 
tuberculosis  in  the  more  obscure  case  of  subacute  arthritis  in  adults. 

Treatment.  The  original  focus  of  infection  in  the  urethra,  tubes,  eye,  &c, 
must  be  dealt  with  as  effectively  as  possible  {see  Genito-urinary  Surgery). 
The  local  affection  is  little  affected  by  drugs,  but  salicylates  may  relieve 
the  pain,  while  iron,  iodides,  and  cod-liver  oil  are  worth  a  trial.  The  joint 
should  be  kept  on  splints  in  the  early  stages  and  pain  relieved  by  the  use 


lo  l  A  TEXTBOOK  OF  SURGERY 

t.t  passive  congestion  by  Bier's  method.  As  the  inflammation  quiets  down 
massage  and  exen  ise  may  be  cautiously  commenced  to  prevent  adhesions 
causing  ankylosis,  passive  congestion  being  still  employed.  In  the  more 
Bevere  cases  vaccines  made  from  the  patient's  own  organisms  should  be 
employed.  Where  there  is  much  effusion  opening  the  joint  and  washing 
out  with  dilute  hiniodide  of  mercury  is  good  treatment  ;  while  in  the  rare 
suppurative  conditions  opening  the  joint  and  drainage  are  needed.  These 
are  often  very  protracted. 

(II)  Arthritis  due  to  Chemical  Irritant  (gout).  Gouty  arthritis  is 
clue  to  a  deposit  of  sodium  urate  in  the  cartilages  and  ligaments  of  joint, 
and  is  one  of  the  expressions  of  the  "  uric-acid  diathesis  "  or  inability  of  the 
patient  to  deal  with  "  purin  bodies  "  or  complex  nitrogenous  materials. 
The  joints  form  one  of  the  clearing-houses  for  excess  of  uric  acid  in  the 
system.  The  pathology  and  treatment  of  gout  are  discussed  in  works  on 
internal  medicine,  while  its  interest  to  the  surgeon  is  from  the  view-point 
of  diagnosis,  since  it  may  be  confused  with  other  forms  of  acute  arthritis 
or  even  of  cellulitis. 

Points  in  an  attack  of  arthritis  suggestive  of  gout  are  a  very  sudden 
onset  at  n'ght.  causing  the  patient  to  wake,  the  pain  being  agonizing.  The 
first  appearance  of  the  disease  is  usually  in  the  metatarso-phalangeal  joint 
of  the  great  toe  of  a  middle-aged  patient.  There  is  often  remission  of  the 
pain  in  the  morning,  and  though  the  joint  appear  cedematous,  red,  and 
obviously  acutely  inflamed  the  general  condition  is  quite  good,  only  moderate 
fever  being  present,  the  condition  being  much  better  than  in  the  case  of  a 
similar  arthritis  due  to  pyogenic  organisms  or  a  cellulitis.  The  joint  appears 
very  acutely  inflamed,  the  skin  being  red,  swollen,  shiny  and  waxy-looking, 
but  this  condition  arises  much  more  rapidly  in  gout  than  in  pyogenic  infec- 
tions.  Other  signs  of  gout  may  be  present,  such  as  small  nodules  of  urates 
(tophi)  in  the  edge  of  the  cartilage  of  the  ear,  and  a  history  of  previous 
attacks  in  the  great-toe  joint  may  be  obtained.  The  patient  is  usually 
florid  and  well  nourished  with  high-tension  pulse  and  urine  of  high  specific 
gravity.  A  consideration  of  these  points  may  lead  the  practitioner  to 
avoid  opening  a  gouty  great- toe  joint  or  incising  the  dorsum  of  the  foot 
for  an  apparent  cellulitis,  which  is  really  a  gouty  tarsal  joint,  for  although 
opening  a  gouty  joint  will  do  but  little  harm,  if  done  with  aseptic  precautions, 
it  is  quite  unnecessary. 

In  gouty  joints  of  old-standing  where  there  are  large  deposits  of 
urates  around  the  joint  (chalk-stones)  which  tend  to  ulcerate  through  the 
skin,  there  is  no  reason  why,  if  causing  disability,  they  should  not  be  removed 
by  incision  to  save  time. 

(II I  j  Imkctivk  Arthritis  of  Subacute  or  Chronic  Nature.  Tuber- 
culosis and  syphilis  of  joints  alone  demand  special  description,  but  under 
this  heading  come  also  leprosy,  actinomycosis,  and  madura  disease  when 
affecting  joints,  while,  as  has  been  mentioned  above,  some  cases  of  gonor- 
rhceal  rheumatism  of  a  subacute  nature  closely  resemble  tuberculous 
disease. 


TUBERCULOSIS  OF  JOINTS  405 

(a)  Tuberculosis  of  Joints.  The  infection  is  in  most  instances  of  blood- 
borne  origin  :  slight  injuries  to  joints  may  form  a  suitable  nidus  for  infec- 
tion, as  in  pyogenic  infections  of  bones  and  joints.  More  rarely  does  the 
infection  spread  from  diseased  structures  in  the  neighbourhood,  as  from 
tuberculous  bursas.  The  initial  infection  may  be  in  the  synovial  membrane 
or  under  the  articular  cartilage  in  the  cancellous  tissue  of  the  epiphysis, 
occasionally  on  the  diaphyseal  side  of  the  epiphyseal  line,  bursting  later 
into  the  joint.  The  synovial  membrane  is  more  often  the  point  of  origin 
in  adults  and  the  end  of  the  bone  in  children,  but  this  varies  considerably 
with  different  joints. 

The  underlying  process  is  the  same  as  in  tuberculosis  elsewhere.  There 
is  a  proliferation  of  fixed  connective-tissue  cells  which  form  the  small  masses 
of  spindle-shaped  "  epithelioid  "  cell  known  as  "  tubercles,"  in  the  centre  of 
which  caseation  or  necrosis  takes  place,  often  with  formation  of  giant  cells. 
The  necrosing  tubercles  coalesce  and  caseating  masses  are  formed,  or  healing 
fibrosis  is  the  dominant  factor  and  there  is  much  fibrous  tissue  produced. 
In  any  case  there  is  a  formation  of  tuberculous  granulation  tissue,  which 
may  (1)  fibrose  or  (2)  give  out  large  fluid  effusion  or  (3)  break  down  with 
ulceration  or  suppuration,  forming  cold  abscesses  and  sinuses,  with  con- 
siderable destruction  of  bone. 

These  differences  in  the  course  of  the  disease  allow  of  dividing  the  con- 
ditions met  with  into  three  main  groups,  as  in  the  case  of  tuberculosis 
of  the  peritoneum:  (1)  the  fibrosing  or  "quietly  necrosing"  type; 
(2)  hydrarthrosis  ;    (3)  the  suppurative  and  ulcerative  form. 

(1)  In  the  quietly  necrosing  type  the  whole  process  is  very  insidious  : 
formation  of  tubercles  in  the  synovial  membrane  goes  on  with  little  pain  or 
swelling,  the  cartilages  are  eroded,  and  the  granulation  tissue  formed  between 
the  bare  and  carious  ends  of  the  bones  readily  organizes  and  ankylosis 
occurs,  the  patient  noticing  little  but  some  stiffness  of  the  joint.  The 
shoulder  is  the  joint  usually  affected  in  this  manner. 

(2)  This  variety,  in  which  there  is  considerable  effusion  and  development 
of  hydrarthrosis,  is  the  result  of  infection  of  the  synovial  membrane  and  is 
more  common  in  adults.  The  process  is  distinctly  chronic  ;  there  is  but 
slight  thickening  of  the  synovial  membrane,  the  inside  of  which  is  studded 
with  miliary  grey  tuberclesr  which  tend  to  fibrose  rather  than  to  caseate. 
The  effusion  from  these  tubercles  leads  to  considerable  distension  of  the 
joint  (one  form  of  hydrops  articuli).  The  cartilages  and  bones  may  escape 
for  a  long  time  or  remain  unaffected  altogether,  the  condition  healing  by 
fibrosis  with  a  certain  amount  of  ankylosis  from  contraction  of  the  capsule. 
Such  cases  as  the  last  are  then  to  be  looked  upon  as  tuberculous  synovitis. 
The  condition  may,  however,  progress,  with  caseation,  suppuration,  and 
ulceration  as  in  the  next  type. 

(3)  The  pulpy  ulcerative  and  suppurative  type  is  that  most  usually  seen, 
especially  in  children.  This  may  originate  as  caries  of  the  cancellous  bone 
of  the  epiphysis  or  in  the  synovial  membrane.  In  either  case  tubercu- 
lous granulation  tissue  invades  the  joint,  the  articular  cartilage  is  eroded 


106  \  TEXTBOOK  OF  SURGERY 

aud  destroyed,  the  ends  of  the  bones  are  carious,  the  joint  filled  with 
granulation  tissue,  and  the  synovial  membrane  thick  and  pulpy  (white 
swelling).  There  is  little  fluid  inside  the  joint  unless  suppuration  has  taken 
place  from  breaking  down  of  the  caseous  loci,  and  this  seldom  occurs 
for  some  time.  The  liquefaction  of  the  caseous  material  forms  cold  abscesses 
in  and  about  the  joint  which  track  slowly  along  the  paths  of  least  resistance 
to  the  surface  and  ultimately  hurst  through  the  skin  unless  the1  process  be 
checked.  Sinuses  result  from  the  bursting  of  these  cold  abscesses,  which 
become  infected  with  pyogenic  organisms,  and  the  condition  goes  from  bad 
to  worse.  In  other  cases  the  process  of  destruction  is  more  than  counter- 
balanced by  healing  fibrosis  and  the  progress  is  stayed,  healing  taking  place, 
usually  with  ankylosis. 

Results.  (1)  Where  the  infection  is  mild  and  localized  and  is  treated  early 
and  effectively,  the  joint  may  be  restored  to  the  normal. 

(2)  More  commonly  ankylosis  of  varying  firmness  takes  place,  the 
articular  surfaces  being  destroyed. 

(3)  Where  secondary  infection  has  taken  place  through  the  sinuses 
hectic  fever,  wasting,  and  amyloid  disease  may  necessitate  amputation. 

(i)  Occasionally  generalized  (miliar)')  tuberculosis  may  arise.  This  has 
occurred  after  forcible  straightening  of  deformed  tuberculous  joints  while 
the  disease  was  still  active. 

Signs.  These  vary  with  the  type  of  infection.  The  quietly  necrosing 
variety  presents  little  external  signs,  but  the  joint  quietly  becomes  ankylosed. 
In  the  hydropic  type  the  condition  resembles  at  first  other  forms  of  chronic 
synovitis.  The  description  given  below  applies  chiefly  to  the  more  common 
ulcerative  form  of  the  disease. 

A  joint  gradually  ceases  to  perforin  its  functions  and  becomes  ankylosed. 
There  is  pain,  especially  in  moving  the  joint  or  putting  strain  upon  it, 
causing  the  patient  to  use  it  as  little  as  possible  (hence  the  early  limping  in 
hip  disease).  Swelling  is  found  in  most  cases  where  the  joint  is  readily 
palpable,  as  in  the  knee  ;  in  disease  of  the  shoulder  or  hip  the  swelling  is 
hard  to  detect,  unless  considerable.  Stiffness  and  loss  of  function  are 
noted  and  are  more  or  less  according  as  neighbouring  joints  can  take  on  the 
function  of  the  one  diseased.  Thus  stiffness  of  the  shoulder  may  not  be 
noted  for  some  time  owing  to  the  free  movement  of  the  scapula  taking 
its  place.  The  onset  is  very  gradual,  and  it  will  be  found  on  exami- 
nation that  the  movements  of  the  joint  are  restricted  in  all  directions  and 
this  impairment  increases  (this  is  the  case  where  the  bones  and  ligaments 
are  involved);  where  there  is  only  involvement  of  the  synovial  membrane 
with  hydrops  articuli  there  may  be  little  loss  of  movement. 

Swelling  of  the  joint  is  commonly  present,  due  to  the  pulpy  condition  of 
the  synovial  membrane.  Only  in  the  case  of  hydrops  can  the  presence  of 
fluid  be  detected,  nor  is  this  easy  in  the  hip  and  shoulder.  The  swelling  is 
a  general  pulpiness,  causing  loss  of  the  points  of  bony  contour.  Heat  is  but 
slightly  increased,  nor  is  there  any  redness  unless  an  abscess  is  nearly  through 
the  skin.     Enlarged  veins  are  sometimes  noted  in  the  skin  over  the  joint. 


SIGNS  OF  TUBERCULOSIS  OF  JOINTS  407 

Later,  areas  of  softening  and  fluctuation  may  be  detected  near  the  joint 
or  at  a  distance,  as  in  psoas  or  retropharyngeal  abscess  due  to  spinal  caries, 
which  show  that  considerable  breaking  down  of  caseous  material  has  taken 
place.  The  muscles  waste  from  disuse,  and  thus  the  pulpy  joint  appears 
larger  and  as  a  spindle-shaped  tumour. 

The  position  of  the  joint  is  that  which  will  ensure  greatest  ease — either  to 
allow  of  distension  of  the  synovial  cavity,  as  in  the  partial  flexion  of  knee, 
and  the  occasional  eversion  and  flexion  of  the  hip  ;  or  to  save  the  limb  from 
jarring,  as  in  the  flexion  and  adduction  of  the  hip  with  tilting  of  the  pelvis 
and  apparent  shortening  of  the  leg,  which  lessens  the  impact  of  the  foot  with 
the  ground. 

Later,  the  softened  ligaments  give  way  and  there  results  displacement 
of  the  ends  of  the  bones,  which  would  be  prevented  by  the  intact  ligaments. 
The  backward  displacement  of  the  tibia  in  chronic  arthritis  of  the  knee  is 
m  good  example  of  this  sort  of  deformity  :  dislocation  of  the  hip  may  also 
occur,  though  this  is  less  common.  Pain  is  usually  made  worse  by  move- 
ments, and  when  the  cartilages  are  destroyed  there  occur  the  well-known 
"  starting  pains  "  at  night  :  just  as  the  patient  is  dropping  off  to  sleep, 
the  muscular  spasm  which  in  the  earlier  stages  of  disease  keeps  the  joint 
rigid  and  prevents  the  eroded  surfaces  from  moving  on  each  other  relaxes, 
and  these  surfaces  grate  together,  causing  pain  and  sudden  tightening  again 
of  the  muscles  with  a  painful  start,  which  may  prove  very  wearing  to  the 
patient  and  requires  splints  or  extension  as  treatment. 

The  course  of  tuberculosis  varies  greatly  in  duration.  In  favourable 
cases  a  joint  may  heal  in  six  months  or  less ;  more  often  a  year  is  needed, 
but  cases  not  infrequently  hang  on  for  several  years  before  healing  takes 
place  or  amputation  becomes  necessary.  Moreover,  after  remaining  healed 
for  a  number  of  years  (even  as  long  as  twenty  or  more)  such  healed  joints 
may  again  break  down  with  the  original  disease. 

Diagnosis.  The  ordinary  pulpy  type  with  "  white  swelling  "  occurring 
in  a  child  in  a  superficial  and  palpable  joint,  as  the  knee  or  elbow,  is  easily 
recognised  ;  but  the  less  common  varieties  with  much  effusion  or  early 
ankylosis,  or  where  the  pulpy  type  occurs  in  deep-seated  joints  as  the  hip 
or  shoulder,  are  sometimes  hard  to  diagnose  accurately  as  to  their  cause. 
Moreover,  even  in  a  palpable  joint  after  pain  and  disability  have  commenced 
some  time  may  elapse  before  definite  physical  signs  can  be  made  out.  In 
some  of  these  cases  radiographs  are  very  helpful,  showing  that  carious  foci 
of  the  bono  are  the  point  of  origin  and  also  enabling  us  to  recognize  such 
conditions  as  myeloid  growths  or  displaced  epiphyses  {e.g.  of  the  hip)  at  an 
early  stage.  The  form  with  much  effusion  (hydrops)  is  uncommon  in 
children,  in  whom  such  conditions  are  more  often  due  to  congenital  syphilis  ; 
while  in  adults  this  type  has  to  be  distinguished  from  osteo-arthritis  and 
gonorrhceal  hydrops.  In  early  adult  life  gonorrhceal  joints  and  chronic 
rheumatoid  conditions  are  likely  to  be  confused  with  tuberculosis  ;  the 
affection  of  several  joints  in  the  former  conditions  will  render  tuberculosis 
unlikely,  while  finding  a  gonorrhceal  urethritis  will  point  to  the  variety  of 


\  TEXTBOOK  OF  SURGERY 

••rheumatism"  present.  In  obscure  cases  exploratory  aspiration  or  even 
incision  may  help,  especially  in  cases  with  effusion,  where  the  diagnosis  is 

often  doubtful  :  a  piece  of  synovial  membrane  may  be  removed  for  section. 
In  old  a<_rc  the  more  common  osteo-arthritis  is  distinguished  by  the  slighter 
impairment  of  mobility  in  spite  of  great  deformity  ;  grating  will  be  noted  on 
moving  the  joint,  while  radiographs  will  show  the  presence  of  osteophytes 
and  absence  of  articular  cartilage-  the  ends  of  the  hones  appearing  close 
together  instead  of  being  separated  by  a  gap  due  to  the  intervention  of  the 
transparent  cartilage. 

Treatment.  It  is  important  to  recognize  that  Nature  is  the  best  healer 
of  tuberculous  joints,  the  patient  recovering  from  his  own  powers  of  dealing 
with  the  tubercle  bacillus,  and  only  in  special  cases  is  aggressive  surgical 
interference  warranted.  This  does  not.  however,  mean  that  these  cases 
are  to  be  neglected  :  on  the  contrary,  we  aim  at  assisting  the  natural  process 
of  cure  by  increasing  the  patient's  powers  of  resistance  and  in  placing  the 
joint  in  the  most  favourable  condition  for  healing. 

As  regards  general  measures.,  these  are  similar  to  those  indicated  in 
tuberculosis  generally,  including  a  generous  diet  rich  in  fats  (milk,  cream, 
eggs,  bacon),  an  open-air  life  (as  far  as  possible)  with  sunshine  in  a  bracing 
climate—which  makes  the  East  Coast,  and  especially  Thanet,  the  place  of 
selection  in  this  country.  Of  drugs,  cod-liver  oil,  iron,  and  arsenic  are 
especially  to  be  commended.  Tuberculin  must  be  regarded  as  experimental 
at  present. 

Local  Treatment.  The  joint  is  to  be  kept  at  rest.  This  means  not  only 
controlling  the  movements  of  the  joint  but  also,  what  is  even  more  important, 
avoiding  all  jarring  and  pressure  inside  the  joint,  e.g.  in  the  case  of  the  lower 
limb  there  must  be  no  weight  on  the  diseased  limb.  In  the  more  acute  stages 
complete  recumbency  is  advisable,  but  as  soon  as  the  condition  is  becoming 
quiescent  a  splint  for  the  diseased  side  with  a  patten  on  the  boot  of  the  sound 
limb  is  advisable,  since  moderate  exercise  improves- the  general  condition 
and  defeats  the  attacks  of  the  bacillus.  The  joint  is  placed  in  the  best 
position  in  which  ankylosis  can  occur  in  case  this  should  supervene.  Care 
must  be  taken  to  alter  the  position  of  the  joint  gradually,  since  if  done 
violently  it  is  likely  to  increase  the  inflammation  in  the  joint:  gradual 
osion  is  the  method  most  generally  useful.  This  will  keep  the  surfaces 
of  the  joint  from  grinding  together,  and  as  the  acute  stage  passes  off  and 
irritability  diminishes  the  joint  can  be  placed  in  a  better  position.  Local 
applications  to  the  join*  in  the  shape  of  Scott's  mercurial  ointment  or  Bier's 
congestive  treatment  do  not  seem  to  be  of  any  real  value. 

Operative  Interference.    This  will  be  needed  in  certain  cases. 

Where  cold  abscesses  form  and  threaten  to  burst  through  the  skin.  If 
detected  early  they  cau  often  he  made  to  subside  by  taking  extra  care  in 
providing  rest  for  the  part,  e.g.  in  caries  of  the  spine  by  placing  the  patient 
in  the  recumbent  position.  If.  however,  such  measures  fail  and  the  abscess 
increases  it  is  most  important  to  prevent  its  bursting  and  forming  a  sinus. 
which  will  certainly  become  infected  sooner  or  later  with  pyogenic  organisms, 


ARTHRECTOMY  AND  EXCISION  FOR  TUBERCLE         409 

to  the  great  detriment  of  the  patient.     Two  methods  are  in  vogue  at  present : 
(a)  aspiration  ;   (b)  incision  and  removal  of  the  abscess  contents. 

(a)  Simple  aspiration  with  a  fine  trochar  and  cannula  is  of  little  use, 
since  the  abscess  contents  are  too  viscid  and  mingled  with  clots  and  curdy 
material  so  as  not  to  pass  readily  through  the  cannula,  and  often  very  little 
pus  can  be  removed.  It  is  better  to  introduce  a  mixture  of  thymol  and 
menthol  or  guaiacol  and  menthol  in  olive-oil,  leaving  this  for  a  few  days 
and  then  aspirating  the  now  liquid  mass  :  after  this  a  solution  of  iodoform 
in  ether  may  be  injected,  the  ether- vapour  being  allowed  to  escape  through 
the  cannula  as  the  ether  boils  from  the  body  heat,  thus  depositing  iodoform 
inside  the  cavity.  Good  results  are  claimed  for  these  methods,  but  we 
question  if  they  are  as  good  as  the  next  plan. 

(b)  If  incision  is  to  be  successful  one  must  not  wait  till  by  its  redness 
and  thinness  the  skin  shows  that  it  is  already  infected,  or  it  will  surely  break 
down  and  a  sinus  result.  If  the  abscess  is  increasing  in  spite  of  complete 
rest  and  other  care,  the  abscess  should  be  opened,  but  not  at  a  dependent 
part,  and  through  a  good  thickness  of  superficial  tissue  (to  lessen  the  risks 
of  infection  with  tuberculous  material  by  gravitation)  ;  the  cavity  is  swabbed 
out  with  sterile  gauze  till  dry  and  free  from  pus  and  granulation-tissue  and 
the  wound  closed — the  cavity  drained  for  twenty-four  hours  to  permit 
escape  of  serum,  which  forms  in  considerable  quantity.  The  wound  is  then 
allowed  to  heal.  This  may  be  repeated  if  necessary  :  rigid  asepsis  is  very 
necessary  in  these  cases. 

Where  a  large  effusion  is  present  the  joint  should  be  opened  by  a  small 
incision  and  washed  out  with  biniodide  of  mercury  in  dilute  solution  (1  in 
5000).  Where  sinuses  form  after  incision  or  aspiration  they  should  be 
injected  with  bismuth  paste  (30  per  cent.). 

Arthrectomy  and  Excision.  These  more  active  measures  are  required 
in  severe  and  advancing  affections.  By  arthrectomy  is  meant  removal  of 
diseased  structures  only,  especially  the  synovial  membrane,  but  also  bone 
and  cartilage,  as  may  be  necessary.  In  an  excision  the  whole  joint  is  removed, 
capsule,  ligaments  and  the  ends  of  the  bones.  The  modern  tendency  in 
the  treatment  of  joints  is  for  the  most  part  conservative,  and  the  classical 
excision  is  seldom  advisable  for  tuberculosis  of  joints.  There  is  no  use  in 
removing  a  mass  of  healthy  tissue  unless  it  is  intended  to  secure  a  movable 
joint  as  at  the  elbow,  for  unless  bone  be  freely  excised  in  this  situation 
ankylosis  will  surely  take  place.  In  most  joints,  however,  ankylosis  is 
aimed  at  and  arthrectomy  becomes  the  operation  of  choice,  but  if  the 
disease  is  spreading  to  the  bones  arthrectomy  may  be  as  extensive  or  more 
so  than  a  classical  excision. 

Arthrectomy  is  indicated  where  the  disease  continues  to  spread  in  spite 
of  conveisative  treatment,  especially  if  the  cartilage  is  destroyed  so  that 
ankylosis  is  certain,  or  if  cold  abscesses  persist  in  forming,  in  spite  of 
aspiration  or  incision.  The  knee,  elbow,  and  ankle  are  most  suitable 
for  this  treatment :  the  joint  being  exposed  by  a  suitable  incision ; 
all  diseased    material — whether    bone,  cartilage,   or    synovial    membrane 


4io  \  TEXTBOOK  OF  SURGERY 

— carefully  removed    with   knif<  sjouge,  saw,   and   sharp  spoon, 

all  bleeding-points   secured  and  the  joint   washed    out   with   solution   of 
biniodide  of  mercury  1  in  -  I  he  limb  is  kept  on  a  splint  for  some 

months  aft  ation,  but  if  the  latter  is  successful  this  part  of  tie-  treat- 

ment will  be  much  shorter  than  in  a  similar  case  treated  by  simply  scraping 
sinus  splinting.     Formal  excisions  are  little  used  at  present  because 

the  amount  of  bone  removed  is  likely  to  interfere  with  the  growth  of  the 
limb  from  injury  to  the  epiphysis  ;    moreover,  the  results  of  conservative 

•  tnent  are  on  the  whole  very  good.  An  excision  should  be  on  the  lines 
of  arthrectomy  :  diseased  tissues  should  be  removed  in  a  careful  and  orderly 
manner,  paying  attention  not  only  to  the  bones  but  removing  all  diseased 

vial  membrane  with  its  diverticula,  such  as  the  suprapatellar  pouch  in 
the  case  of  the  knee-joint. 

Indications  for  excision  are  :  (a)  Where  the  disease  is  advancing  and 
the  joint  badly  disorganized.  In  many  such  cases  excision  will  not  be 
sufficient  but  amputation  be  necessary,  (b)  Where  the  disease  is  advancing 
and  it  is  desired  to  preserve  a  movable  joint,  (c)  Where  the  position  of  the 
joint  is  bad  and  ankylosis  is  inevitable  and  the  position  cannot  be  improved 
bv  extension,  or  where  firm  ankylosis  is  present.  Whether  arthrectomy  or 
rion  be  practised  the  joint  must  be  kept  in  splints  and  strains  and  jarring 
of  the  joint  avoided  for  about  three  to  four  months  after  the  operation- 
wound  appears  soundly  healed,  since  it  is  impossible  to  guarantee  that  a 
com]  oval  of  the  whole  disease  has  been  effected,  and  some  minute 

foci  of  disease  may  have  been  left  behind  which  may  lead  to  recurrence  of 
the  d  these  precautions  be  adopted.     The  knee  and  elbow  are 

•  suitable  for  excision,  the  ankle  fairly  suitable,  while  the  hip.  wrist, 
and  shoulder  will  seldom  be  excised  for  tubercle  ;  though  in  a  few  cases 
operation  on  the  lines  of  arthrectomy  with  considerable  removal  of  bone 
will  be  suitable.  Both  varieties  of  operation  will  be  more  satisfactory  in 
children — bearing  in  mind,  however,  the  liability  of  the  operation  to  inter- 
fere with  growth  of  the  lirnb,  and  hence  avoiding  the  epiphyseal  line. 

In  middle  life  and  old  age  the  results  of  these  operations  are  so  poor 
that  they  are  not  worth  the  attempt,  and  amputation  is  the  only  resource 
if  the  disease  advances,  so  that  operation  becomes  necessary. 
Amputation  is  the  last  res  id  is  indicated  : 

In  old  persons  where  the  disease  is  advancing  in  spite  of  conservative 
measures. 

2    Where  disorganization  of  the   joint  is  rapid   and  the  presence  of 

Eiders    recovery    unlikely   after    several    attempts    made 

by  arthrectomy,  scraping,  &c.,  have  proved  ineffectual,  or  where  tie-  die 

reading  along  the  bones  (in  children  as  long  as  the  general  condition 

should  be  very  chary  of  .-acri)icin<_r  a  limb  for  this  cause, 

tion  of  the  joint  may  appear  to  be). 

(3)  Where  the  general  condition  of  the  patient  is  growing  worse,  « - j 1 1 1 «-i 

from  development  of  tuberculous  foci  elsewhere  or  from  hectic  fever  and 

lardaceous  di.-<-a>"  caused  by  secondary  pyogenic  infection  of  the  sinuses. 


SYPHILIS  OF  JOINTS  411 

though  in  children  even  in  such  cases  free  excision  m  -  ' 

Where  a  focus  of  tubercle  exists  elsewhere,  e.g.  in  the  lung,  amputation  of  a 
tuberculous  limb  may  greatly  improve  the  patient's  condition  and  even  - 
life. 

Amputation  in  cases  where  the  joint,  though  healed,  is  flail-like  and  the 
limb  useless  should  not  be  done,  at  all  events  in  young  subjects,  till  a  fair 
trial  of  bone-grafting  has  been  made. 

(b)  Syphilis  of  Joints.  <  oinpared  with  tuberculosis,  infection  of  j'  te 
with  the  spirochete  are  uncommon.  The  effects  of  this  organism  are  found 
in  both  the  congenital  and  acquired  forms  of  tin 

Acquired  Syphilis.  (1)  In  the  secondary  stasre  simple  synovitis  occurs, 
which  in  its  milder  forms  gives  rise  to  the  well-known  "  rheumatic  ''  pains 
and  usually  only  lasts  a  short  time.  There  may.  however,  be  considerable 
effusion  or  hydrops  articuli,  and  this  is  likely  to  be  symmetrical  like  other 
secondary  lesions.  The  cautious  practitioner  will  be  on  the  look-out  for 
chancres,  genital  or  extra-genital,  and  rashes  of  the  skin  in  cases  of  obscure 
"  rheumatism  "  :  the  Wassermann  reaction  will  disclose  the  nature  of  the 
disease. 

(2)  In  the  tertiary  stage,  gummatous  inflammation  of  the  synovial  and 
periarticular  tissues  may  occur,  the  case  presenting  itself  with  one  or  more 
firm  nodes  in  the  synovial  area  about  a  joint,  especially  the  knee-joint. 
These  are  but  slightly  painful,  and  fairly  soon,  if  superficial,  the  skin  over 
them  reddens  and  breaks  down,  when  the  typical  gummatous  ulcer  with 
punched-out  edges  and  yellow,  sloughy  floo? 

(3)  A  much  less  common  condition,  also  found  in  tertiary  syphilis,  is  the 
chondro-arthritis  of  Virchow.  Clinically  there  is  stiffness  of  the  joint  with 
grating  and  some  effusion,  as  in  osteo-arthritis  (which  this  condition  resembles), 
but  there  are  no  osteophytes  or  "  lipping  ""  of  the  bones  and  the  cartilage  is 
not  eroded  at  the  place  of  greatest  pressure  and  in  linear  streaks,  due  to 
attrition  of  the  articulating  surfaces,  as  in  the  latter  disease,  but  in  rounded 
pits,  not  at  the  bearing  surface  of  the  joint.  In  addition  there  may  be 
gummatous  infiltration  of  the  synovial  membrane  and  rarefaction  of  the 
bone  locally. 

Congenital  Syphilis.  (1)  Allusion  has  been  made  already  to  the  acute 
arthritis  of  infants,  which  is  an  epiphysitis  largely  of  pyogenic  causation  but 
originating  in  subjects  of  congenital  syphilis  in  the  first  or  second  year. 

(2)  About  the  time  of  the  second  dentition  effusion  into  the  joints, 
especially  the  knees,  is  found  associated  with  chronic  inflammation  of  the 
synovial  membrane,  which  is  inflamed  and  infiltrated  with  granulation- 
tissue.  The  condition  appears  rapidly  as  a  painless  synovitis,  usually 
symmetrical,  though  only  one  knee  may  be  affected.  Other  signs  of  con- 
genital syphilis  may  be  noted,  such  as  the  depressed  nose.  Hutching 
teeth,  or  interstitial  keratitis,  and  Wassermann's  reaction  will  be  positive. 
In  any  case  the  large  effusion,  pail  -  38,  and  slight  impairment  of  the 
functions  of  the  joint  will  render  the  d  s  sis  of  tuberculosis  unlikely  in 
a  child.     Thes<        3  -  are  somewhat  refractorv  to  treatment,  and  if  not 


U2  A  TEXTBOOK  OF  SURGERY 

subsiding  on  specific  remedies  and  clastic  pressure  over  the  joint  it  will  be 
well  to  open  the  joint  and  wash  out  with  dilute  biniodide  of  mercury. 
The  treatment  of  the  other  varieties  is  constitutional  and  specific  for 

syphilis. 

(IV)  The  Rheumatoid  Aitections  of  Joints.  The  affections  in  this 
division  present  considerable  resemblance  anatomically  but  differ  in  causa- 
tion as  far  as  this  is  understood.  In  many  instances  the  ultimate  pathology 
is  still  obscure  and  presents  a  fertile  field  for  investigation. 

Anatomy.  The  main  underlying  changes  are  of  chronic  inflammatory 
and  degenerative  nature,  though  there  may  be  an  initial  acute  stage,  as, 
for  example,  in  gout,  haemophilia,  and  some  neuropathic  joints.  These 
changes  affect  all  parts  of  the  joints  :  the  bones  are  rarefied  in  some  parts  and 
sclerosed  elsewhere  ;  the  ligaments  softened  and  stretched  or  thickened  and 
contracted  ;  the  cartilage  fibrillated  or  velvety,  and  later  eroded  ;  while 
hypertrophic  growth  of  cartilage  may  occur  in  the  chronically  inflamed 
synovial  fringes,  resulting  in  the  formation  of  loose  bodies.  Effusion  is 
common,  though  some  of  these  joints  are  "  dry."  Osteophytes  grow  from 
the  edges  of  the  bones,  which  when  diffuse  produce  the  effect  of  "  lipping." 
Causation.  In  some  instances  the  causation  of  the  affection  is  definitely 
known  and  we  can  separate  from  the  large  rheumatoid  group  arthritis 
due  to  gout,  haemophilia,  and  nervous  conditions.  There  remain,  however, 
a  large  number  of  cases  which  are  generally  grouped  together  under  the 
name  osteo-art/tntis.  which  have  much  in  common  anatomically  but  are  due 
to  widely  different  causes  or  combinations  of  causes. 

(a)  Osteo-arthritis  (also  known  as  arthritis  deformans,  rheumatic  gout, 
rheumatoid  arthritis,  arthritis  sicca,  chronic  rheumatism,  &c). 

The  cases  fall  into  certain  groups,  according  as  to  whether  one  or  several 
joints  are  affected  or  from  the  age  of  onset  or  the  amount  of  changes  present 
in  different  parts  of  the  joints  :  thus  in  some  types  the  capsule  and  ligaments 
are  affected  while  the  cartilage  and  bone  may  escape  for  many  years.  It  is 
still  uncertain  whether  the  conditions  which  resemble  each  other  anatomi- 
cally are  also  related  in  causation,  and  thus  nomenclature  is  difficult. 

Causation,  (a)  Infection  plays  a  considerable  part.  After  acute  infec- 
tions have  healed  the  damaged  joint  is  apt  to  develop  changes  closely 
resembling  those  which  develop  quietly  and  insidiously.  Influenza  precedes 
the  onset  of  the  disease  in  a  good  many  instances,  and  the  gonococcus  and 
other  organisms  are  responsible  and  have  been  found  in  some  cases  (Fig.  186). 
<  )ral  and  intestinal  sepsis  account  for  a  certain  number  of  cases,  though  these 
causes  are  probably  overrated  by  enthusiasts  in  these  branches  of  medicine  : 
nevertheless,  it  seems  reasonable  to  deal  with  infective  foci,  whether  in  the 
mouth,  intestine,  or  urethra.  It  is  questionable  to  what  extent  toxines, 
apart  from  invasion  by  organisms,  can  produce  the  disease.  Again,  the 
acute  onset  of  some  of  the  polyarticular  cases,  with  fever,  enlargement  of 
lymphatic  glands  and  spleen,  suggests  infection. 

(b)  Nervous  Influence.  Quite  apart  from  the  well-known  neuropathic 
joints  of  tabes  and  syringomyelia,  there  is  reason  to  believe  that  alteration 


OSTEOARTHRITIS  413 

of  nervous  influence  accounts,  in  part  at  any  rate,  for  some  types  of  joint 
affection.  The  rapid  wasting  of  muscles,  the  glossy  and  atrophic  skin  and 
pain  associated  with  neuritis,  favour  this  view. 

(c)  Age  is  also  a  factor,  most  cases  occurring  in  the  middle-aged  and 
elderly  ;  and  the  joints  may  age  more  rapidly  than  the  patient's  age  would 
lead  one  to  believe,  just  as  the  arteries  do.  Still,  many  similar  cases  occur 
in  the  young. 

(d)  Trauma  is  another  cause,  especially  in  the  cases  coming  into 
surgical  notice,  and  may  be  associated  with  fracture-dislocations  or  definite 
injury  to  joints,  usually  in  the  elderly.  Such  affections  may  also  occur  in 
other  joints  (in  the  same  limb)  than  the  one  injured.  Thus  after  a  Colles's 
fracture  osteo-arthritis  of  the  shoulder  and  elbow  on  the  same  side  often 
greatly  increases  the  disability  in  old  persons.  It  is  uncertain  whether  this 
arises  from  associated  injury  of  these  joints  of  minor  degree  or  from  disuse 
when  the  fracture  is  confined  in  splints  (a  point  against  prolonged  splinting 
in  old  persons),  or  whether  some  obscure  nervous  influence  is  at  work. 

Anatomy.  In  the  early  stage  there  is  usually  thickening  and  congestion 
of  the  synovial  membrane  and  effusion  of  turbid  fluid  into  the  joint.  The 
synovial  membrane  becomes  hypertrophied,  forming  fringes  and  villous 
growths  in  which  cartilaginous  nodules  may  grow  to  a  large  size  and,  becoming 
detached,  constitute  one  form  of  loose  bodies.  The  articular  cartilage 
becomes  fibrillated  at  right-angles  to  its  surface  so  as  to  resemble  the  pile 
of  velvet,  and  is  gradually  worn  away  by  friction  with  the  corresponding 
surface,  leaving  the  bone  bare.  The  bone  where  the  cartilage  is  removed 
becomes  sclerosed  or  "  eburnated  "  so  as  to  resemble  porcelain,  while  in 
other  parts  there  is  rarefaction  and  absorption  of  bone,  e.g.  in  the  neck  of 
the  femur,  while  at  the  edges  of  the  articular  surface  the  bone  becomes 
hypertrophied,  growing  out  as  prominences  the  "  osteophytes  "  or  "  lipping." 
These  may  fuse  with  those  of  the  corresponding  bone  and  cause  ankylosis. 
The  changes  do  not  occur  to  the  same  degree  in  all  parts  ;  thus  the  cartilage 
may  be  more  affected  than  the  capsule  and  vice  versa.  The  capsule  and 
ligaments  may  become  calcified  ;  great  wasting  of  muscles  is  common  where 
the  movement  is  much  impaired,  and  contractures  in  the  flexed  position 
are  common. 

Clinically  the  following  types  may  be  recognized  :  (a)  The  mon-articular 
(arthritis  deformans)  ;  (b)  the  limited  polyarticular  (Heberden's  nodes)  ; 
(c)  the  advancing  polyarticular  (chronic  rheumatism)  ;  (d)  the  form  in 
children  ;    and  (e)  that  affecting  the  spine  (spondylitis  deformans). 

(a)  Arthritis  Deformans.  This  is  usually  non-articular  and  often  due  in 
great  part  to  preceding  trauma,  generally  affecting  large  joints  such  as  the 
knee  or  hip.  The  affection  is  characterized  by  great  bony  changes  and  the 
growth  of  large  osteophytes,  giving  the  bone  when  the  upper  end  of  the 
femur  is  affected  the  appearance  of  a  mushroom,  while  there  is  loss  of  bone 
in  otherparts,  e.g.  the  neck  of  the  femur.  Loss  of  cartilage  with  eburnation 
of  the  underlying  bone  is  marked  in  these  cases ;  loose  bodies  common  ; 
effusion  may  be  present  or  not.     Clinically  the  joint  becomes  stiff,  grates 


H4  A  TEXTBOOK  OF  SURGERY 

and  is  painful,  especially  in  damp  weather  and  after  resting.    Later,  defor- 
mity, muscular  atrophy,   and   osteophytes   lire, .me  obvious,   and  finally 

ankylosis  may  occur. 

(/>)  The  limited  polyarticular  form  occurs  usually  in  old  persons  and 
seldom  under  forty  or  fifty,  with  stillness  of  tic-  finger-joints  and  formation 


Fig.  Hi".     Osteo-arthritis  of  the  hip  (X-ray),  Bhowing  the  shortened  neck  with  its 
diminished  angle  of  attachment  to  the  shaft  and  the  large  mushroom-like  head  due  to 
-<ive  production  of  osteophytes. 

of  little  hard  lumps  or  osteophytes  on  the  side  of  the  distal  phalanges  of  the 
fingers  (Heberden's  nodes)  ;  there  is  loss  of  cartilage  and  eburnation.  There 
is  considerable  deformity  of  the  fingers,  which  deviate  to  the  ulnar  side  and 
are  flexed  at  some  joints  while  hyperextended  at  others;  the  large  joints 
are  seldom  affected.  The  hands  ultimately  become  useless,  but  it  takes 
many  years  for  this  to  result.  This  form  may  come  on  after  influenza  or 
the  menopause  in  women,  and  is  aggravated  by  damp,  cold,  anaemia,  and 
malnutrition. 

(c)  The  progressive  type,  or  chronic  rheumatism,  occurs  in  younger 
persons,  starting  between  thirty  and  forty  or  younger,  and  affects  large 
and  small  joints,  often    symmetrically.      It  is  frequent  in  women  during 


OSTEOARTHRITIS  ±lo 

pregnancy,  lactation,  or  the  menopause,  sometimes  following  influenza.  The 
onset  is  insidious,  with  swelling  and  stiffness,  sometimes  redness  of  the 
joints,  and  more  or  less  effusion.  There  is  loss  of  cartilage,  causing  grating, 
while  osteophytes  develop.  The  muscles  waste  and  the  skin  becomes 
glossy ;  finally  nearly  all  the  joints  become  ankylosed  by  interlocking  of 
osteophytes  and  calcification  of  ligaments,  and  there  is  extensive  deformity — 
the  elbows,  hips,  and  knees  being  flexed  and  fixed  so  that  in  shape  the  un- 
fortunate patient  resembles  an  arm-chair.  There  are  periods  of  improve- 
ment, often  of  long  duration,  but  relapses  are  common  and  the  tendency  is 
ultimately,  it  may  be  after  many  years,  to  ankylosis  and  complete  help- 
lessness. 

(d)  In  children  the  condition  develops  acutely  with  fever,  enlargement 
of  the  lymphatic  glands,  and  spleen  (Still).  The  joints  become  spindle- 
shaped  from  thickening  of  the  capsular  tissues,  there  is  little  affection  of 
the  bones,  no  osteophytes  are  formed,  and  the  cartilages  are  not  eroded  ; 
hence  there  is  stiffness  but  no  grating. 

The  disease  occurs  during  the  second  dentition,  is  symmetrical,  large 
and  small  joints  are  affected,  and  there  is  marked  muscular  wasting. 

(e)  The  vertebral  form  is  considered  under  Diseases  of  the  Spine  at  the 
end  of  the  present  section. 

Treatment.  In  general  cold  and  damp  are  to  be  avoided,  and  living  in 
a  warm,  dry,  sunny  climate  is  the  best  way  of  controlling  this  troublesome 
disease. 

The  general  health  should  be  attended  to  and  nutrition  maintained  by 
generous  diet,  especially  with  fatty  foods.  Of  drugs,  iron,  arsenic,  iodide 
of  iron  and  potassium,  and  cod-liver  oil  are  worth  noting,  while  the  pain 
may  be  relieved  when  severe  by  antipyrin,  pyramidon.  or  local  treatment. 

Local  foci  of  infection  such  as  tonsils,  teeth,  or  the  appendix,  should  be 
removed  or  mitigated.  Whether  altering  the  intestinal  drainage  system, 
as  advocated  by  Lane,  is  really  beneficial  in  these  cases  is  not  sufficiently 
certain  for  us  to  recommend  such  heroic  measures. 

Bath  treatment — whether  hot  air,  hot  water,  hot  brine,  or  hot  mud — 
is  often  beneficial  in  relieving  pain.  Locally  the  joints  should  be  kept 
warm  with  flannel  bandages  and  exercised  in  moderation.  Elastic  pressure 
by  bandaging  over  wool  or  strapping  the  joint  is  useful  where  there  is  much 
effusion.  Massage  also  relieves  pain  and  promotes  absorption.  Baking 
the  joint  with  radiant  heat  relieves  the  pain  and  stiffness  but  does  not  in 
any  sense  cure  the  condition.  Surgical  measures  are  seldom  advisable, 
but  where  the  joint  is  painful  and  dry,  with  grating  from  erosion  of  cartilage, 
oiling  the  joint  by  injection  of  sterile  vaseline  (Rovsing),  2  to  5  c.c,  may 
increase  the  mobility  and  relieve  the  pain.  More  severe  operations  are  only 
advisable  in  a  few  cases.  Thus  excision  of  the  temporo-inaxillary  joint  to 
allow  of  mastication  is  good  treatment,  or  of  the  knee  to  promote  ankylosis 
in  good  straight  position  where  the  joint  is  much  flexed  and  is  the  only  joint 
affected.  Attempts  to  form  a  new  joint  (arthroplasty)  by  removal  of 
osteophytes  and  inserting  a  flap  of  fascia  and  fat  (Murphy)  will  be  the 


•I  If. 


A  TEXTBOOK  OF  SURGERY 


operation  of  the  future  in  selected  cases,  usually  where  but  one  or  two  joints 
are  affected. 

(b)  Chronic  gouty  arthritis  is  distinguished  by  the  formation  of  chalk- 
Btones  «>r  deposits  of  urate  of  soda  about  the  joint  and  in  its  capsule,  and 
needs  no  further  mention,  being  fully  described  in  works  on  internal  medicine. 

(c)  Neuropathic  Affec- 
tions oj  Joints  {Charcot's 
joints).  Changes  in  joints 
resembling  those  found 
in  osteo-arthritis  are 
found  associated  with 
various  diseases  of  the 
nervous  system,  especi- 
ally in  tabes  and  syrin- 
gomyelia ;  also  from 
nerve  injuries  and  neu- 
ritis, whether  leprous, 
diabetic  or  syphilitic  ; 
and  in  such  conditions 
as  spina  bifida  and  hemi- 
plegia. 

The  onset  of  the  arth- 
ritis is,  however,  usually 
sudden,  the  joint  quickly 
and  usually  painlessly 
filling  with  fluid.  Soon 
atrophic  and  hypertro- 
phic alteration  of  bone, 
cartilage  and  capsule 
take  place.  In  some 
conditions  the  hypertro- 
phic changes  are  most 
evident,  the  condition 
closely  resembling  arthritis  deformans  ;  such  cases  are  more  often  the  result 
of  syringomyelia  but  do  occur  in  tabes.  More  often  in  tabes  the  degene- 
rative changes  are  predominant,  the  ends  of  the  bones  melting  away  so  that 
the  joint  becomes  abnormally  mobile  (e.g.  lateral  movement  is  found  in  the 
extended  knee-joint)  or  may  become  entirely  flail-like.  The  course  varies  : 
there  may  be  remissions  and  periods  of  improvement,  but  the  general 
tendency  is  to  complete  disorganization  of  the  joint  with  displacement  or 
dislocation  and  great  loss  of  stability  ;   ankylosis  less  often  results. 

One  type  of  this  condition  is  known  as  Movan's  disease,  in  which  there 
is  disorganization  of  the  phalangeal  joints  with  anaesthesia  of  the  fingers, 
due  to  a  variety  of  syringomyelia. 

Diagnosis.  Neuropathic  joints  are  to  be  distinguished  from  osteo- 
arthritic  changes  by  the  rapid  onset  (this  is  more  marked  in  tabetic  than 


Fig.  168.     Disorganization  of  the  left  elbow-joint  with 
great  effusion,  due  to  syringomyelia. 


CHARCOT'S  JOINTS  417 

syringomyelic  affections),  the  painlessness,  and  tendency  to  a  flail  condition 
rather  than  to  rigidity  and  ankylosis  ;  but  in  the  early  stages  the  physical 
signs  are  often  very  similar,  and  in  doubtful  cases  of  an  osteo-arthritic  nature 
examination  should  always  be  made  for  cutaneous  areas  of  anaesthesia  to 
pain,  heat  and  cold  (syringomyelia),  or  loss  of  knee  jerks,  Romberg's  sign, 
lightning  pains  and  pupillary  changes  (tabes),  or  affections  of  the  cord,  as 
spina  bifida. 

In  syringomyelia  the  wrist,  elbow,  and  shoulder  are  most  often  affected, 
while  in  tabes  the  affection  is  more  often  of  the  joints  of  the  lower  limb, 
though  sometimes  those  of  the  upper  limb  are  affected  also. 

Treatment.  As  the  progress  is  to  destruction,  whatever  be  done,  treat- 
ment can  only  be  palliative,  but  considerable  assistance  may  be  given  by 
the  use  of  apparatus  to  avoid  strain  being  thrown  on  the  joint.  Thus  in 
the  lower  limb  the  weight  of  the  body  may  be  taken  off  the  hip  or  knee 
by  means  of  a  Thomas's  calliper  knee-splint,  and  it  is  important  to  render 
the  affected  limb  as  efficient  as  possible  in  the  case  of  the  leg,  since  there  is 
considerable  risk  that  the  sound  limb  may  become  affected  if  much  extra 
strain  is  thrown  upon  it  from  the  weakness  of  the  damaged  joints  of  the 
other.  By  judicious  rest,  splinting,  elastic  pressure  and  massage,  the 
ultimate  fate  of  the  joint  may  be  postponed  for  a  considerable  time  and 
the  patient  enabled  to  lead  a  useful  existence. 

(d)  Affections  of  Joints  in  Hwmophilia.  In  subjects  of  this  hereditary 
disease  bleeding  may  take  place  in  the  interior  of  joints  either  spontaneously 
or  as  the  result  of  injuries.  The  results  are  similar  to  those  found  in  trau- 
matic osteo-arthritis,  and  no  doubt  the  extravasated  blood  acts  as  a  foreign 
body,  keeping  up  irritation  of  the  joint-tissues.  The  effusion  may  clear 
up  in  the  early  stages  with  but  little  lasting  effect  on  the  joint,  but  repeated 
haemorrhages  lead  to  erosion  of  cartilage,  eburnation  of  the  articular  surfaces 
of  the  bones,  osteophytic  outgrowths,  effusion  into  the  joint,  and  alteration 
in  the  capsule  :  all  the  involved  structures  may  be  stained  brown  with 
altered  blood.  The  ultimate  result  is  a  disorganized  and  crippled  joint 
with  ankylosis  of  varying  degree. 

Treatment.  In  the  initial  condition  of  effusion  of  blood  into  the  joint- 
cavity  this  should  be  restrained  as  far  as  possible  by  elastic  pressure,  which 
will  also  help  to  promote  absorption  :  massage  should  be  used  later  but  not 
for  about  three  weeks,  lest  this  cause  haemorrhage  to  commence  again  ; 
aspiration  of  the  blood  should  not  be  attempted  as  the  small  puncture  may 
bleed  for  weeks.  Later,  where  the  osteo-arthritic  changes  are  fully  deve- 
loped treatment  is  on  the  lines  laid  down  for  that  affection. 

(5)  Functional  Disorders  of  Joints  (hysterical  joints,  neuromi- 
mesis).  The  manifestations  of  hysteria  affecting  joints  take  the  form  of 
contractures,  causmg  gross  and  bizarre  distortions  and  simulating  severe 
types  of  ankylosis.  The  hip  and  ankle  are  most  often  affected,  mimicking 
hip-disease  and  club-foot.  The  following  is  a  typical  example  :  A  girl  of 
fifteen  who  was  in  the  habit  of  having  fits  of  long  duration  but  causing  no 
personal  damage  (regarded  as  epileptic  fits,  but  really  due  to  major  hysteria), 
i  27 


II-  \  TEXTBOOK  OF  sri;<;i:i;v 

was  found  at  the  end  of  one  of  these  to  have  the  right  hip  extraordinarily 
flexed.  The  practitioner  in  charge  thought  it  had  been  dislocated  during 
the  tit.  On  examination  the  joint  was  found  to  be  intact  with  no  swelling 
about  the  joint.  There  was  simply  great  flexion  and  lordosis.  The  patient 
allowed  no  extension  whatever  but  rotation,  adduction,  and  abduction 
wcic  quite  painless  :  nor  was  there  any  fever  or  wasting.  The  great  defor- 
mity without  wasting  or  fever  and  the  fact  that  most  movements  were 
painless  proved  conclusively  that  the  condition  was  a  neurosis,  and  accord- 
ingly the  patient  was  cured  in  a  lew  weeks  by  patiently  persuading  her  that 
nothing  was  the  matter  and  by  causing  her  to  stand  on  the  sound  leg  and 
then  showing  that  the  supposed  contracted  hip  could  he  made  to  move 
freely. 

Diagnosis  in  these  cases  is  made  by  noting  the  great  deformity,  which  is 
moii'  extensive  than  is  found  in  organic  disease  except  in  the  most  advanced 

3.  This  great  deformity  is  unaccompanied  by  fever,  wasting,  swelling, 
effusion  into  the  joint,  or  abscess-formation,  nor  are  then.'  starting-pains 
at  night  or  local  heat  over  the  joint  ;  moreover,  certain  movements  can 
be  freely  performed,  whereas  in  organic  disease  all  movements  are  restricted. 

The  prognosis  is  good  if  treated  early  on  rational  lines,  but  if  allowed  to 
persist,  permanent  deformity  and  contractures,  wasting  of  muscles,  and 
alteration  ot  the  joint  surfaces  will  result. 

Treatment.  The  main  point  is  to  persuade  and  prove  to  the  patient 
t  hat  the  joint  is  perfectly  normal.  In  some  instances  the  medical  attendant 
fault  by  suggesting  the  possibility  of  there  being  something  the  matter 
with  a  joint,  which  the  patient  magnifies  into  a  grave  distortion.  In  tin- 
case  of  hysterical  hip  the  patient  is  made  to  stand  on  the  sound  limb  and 
movements  of  the  trunk  and  affected  limb  are  made  actively  and  passively, 
till  the  patient  is  persuaded  that  much  more  movement  is  possible  than 
she  imagined.  A  few  linn  attempts  of  this  nature  will  cure  the  case  if 
caught  early.  General  tonic  treatment,  massage,  exercise  to  improve  the 
mental  and  physical  tone,  are  often  advisable.  Local  measures,  such  as 
the  battery  or  "  firing  "  the  joint,  are  to  be  strictly  avoided  as  likely  to  draw 
the  patient's  attention  to  the  joint,  which  is  exactly  the  reverse  of  what  is 
wanted  and  thus  likely  to  make  matters  worse.  These  cases  belong  rather 
to  the  physician  and  neurologist  than  the  surgeon  :  even  Christian  Science 
may  have  its  uses  here. 

Hydatid  Disease  of  Joints.  This  may  originate  in  the  joint  itself  or 
spread    from    the    neighbouring    bones.     Suppuration    is    common    in    such 

Neoplasms  of  Joints.  New  growths  of  joints  are  uncommon  except  as 
extensions  from  neighbouring  bones,  e.g.  myeloid  or  other  sarcomas. 

Primary  sarcoma  of  the  synovial  membrane  has  been  described,  resem- 
bling  in  its  early  stages  tuberculous  infection  of  the  pulpy  type.  Diagnosis 
is  hardly  possible  in  the  earlier  stages  :  later,  when  neighbouring  structures 
are  invaded  and  operation  is  undertaken,  the  tumour-mass  will  be  found  to 
be  fleshy  and  not   caseating ;    the  microscope  will  settle  the  matter.    A 


ARTHRECTOMY  AND  EXCISION  419 

wide  excision  followed  by  heavy  doses  of  X-rays,  or  amputation,  is  then 
indicated. 

Opekations  on  Joints.  Aspiration  for  examining  effusion  or  injection 
of  antiseptics  or  lubricants  is  performed  by  passing  a  fine  hollow  needle  into 
the  most  accessible  part  of  the  joint. 

Arthrotomy,  or  opening  a  joint  for  drainage  of  pus  or  extraction  of 
loose  bodies,  is  performed  at  some  point  where  the  joint  can  be  opened  with 
least  damage  to  surrounding  structures.  Where  drainage  is  made  it  is 
important  not  to  drain  too  long,  or  the  irritation  caused  by  the  tube  will 
lead  to  formation  of  more  adhesions  :  the  tube  need  seldom  be  retained  more 
than  a  week.  Where  in  spite  of  simple  drainage  infection  persists  and  is 
severe,  as  showm  by  severe  intermittent  fever,  sweats,  starting-pains,  rigors, 
&c,  it  will  be  often  necessary  to  open  the  joint  more  widely  and  perhaps 
perform  arthrectomy  or  excision. 

Arthrectomy  and  Excision.  Excision  is  the  older  operation,  and  consists 
in  removing  the  articular  ends  of  the  bones  with  little  regard  to  the  extent 
of  the  disease  or  involvement  of  the  synovial  membrane  of  the  joint.  The 
joint  afterwards  may  be  movable  or  fixed.  This  type  of  operation  is  still 
useful  where  in  injuries  involving  joints  replacement  of  fragments  is  not 
possible,  and  in  cases  of  ankylosis  in  bad  position.  In  practically  all  other 
cases  arthrectomy  is  advisable,  especially  in  young  subjects,  since  the  wide 
removal  of  bone,  as  in  formal  excision,  usually  will  involve  the  epiphyseal 
line  and  cause  much  shortening  of  the  limb. 

Arthrectomy  aims  at  removal  of  diseased  tissues  only,  and  is  a  more 
rational  development  of  excision.  The  joint  is  exposed  thoroughly  by 
incision,  without  damage  to  the  ligaments  and  tendons  about  the  joint ;  these 
may  be  displaced  temporarily  with  their  bony  attachments  and  replaced 
at  the  end  of  the  operation.  With  good  exposure  the  diseased  structures 
are  carefully  removed  by  dissection,  including  synovial  membrane,  liga- 
ments, bone,  and  cartilage.  After  operation  the  sound  tendons,  ligaments, 
&c,  are  replaced  and  the  joint  put  up  in  the  most  useful  position  in  case 
ankylosis  takes  place.  This  result  is  likely  to  follow  in  most  cases  owing 
to  extensive  removal  of  cartilage,  but  in  a  few  instances  after  arthrectomy 
a  movable  joint  may  be  expected. 

Arthroplasty.  This  operation  aims  at  restoring  mobility  to  joints 
which  have  become  ankylosed.  The  operation  commences  on  the  lines  of 
excision  or  arthrectomy  :  the  ends  of  the  bones  are  separated  and  fashioned 
to  form  the  new  joint,  sufficient  bone  being  removed  to  permit  of  free 
movement.  Then  a  flap  of  deep  fascia  and  fat  is  placed  between  the  ends 
of  the  bones  to  prevent  union  taking  place  and  ensure  the  formation  of  a 
joint.  In  excisions  for  injury  the  operation  may  be  suitably  finished  in 
this  manner.  This  operation  is  more  suitable  for  the  upper  than  the  lower 
extremity  on  account  of  the  greater  stability  needed  in  the  latter  situation, 
but  Murphy  reports  good  results  from  arthroplasty  of  the  hip  and  knee. 

Transplantation  of  entire  joints  from  cadavers  is  said  to  have  been 
carried  out  successfully.  • 


lj.i  A  TEXTBOOK  OF  Sl'KdKKY 

Arthrodesis  is  a  form  of  excision  performed  to  secure  ankylosis  in  joints 
which  an-  in  an  unstable  or  flail  condition,  usually  from  paralysis  of  the 
muscles  controlling  them  (from  old-standing  infantile  palsy),  in  order  to 
avoid  constant  need  for  repair  to  orthopaedic  instruments,  which  arc  expen- 
sive and  add  to  the  weight  of  an  already  weak  limb.  The  joint  is  opened 
and  the  articular  cartilage  removed,  the  rawed  ends  of  the  bones  being 
tixed  together  with  screws  or  pegs  till  bony  union  is  assured.  The  knee  and 
ankle  are  the  usual  sites  for  this  operation. 

AFFECTIONS  OF  MUSCLES 

The  following  conditions  are  considered  :  paralysis,  spasm,  atrophy, 
and  inflammations.     New  growths  are  hardly  known. 

Paralysis  of  muscles  may  be  of  nervous  or  local  origin.  In  the  section 
on  the  Surgery  of  the  Nervous  System  are  described  the  differences  in 
paralyses  following  affections  of  the  upper  or  lower  segment  of  the  nervous 
system.  In  the  local  primary  affection  of  muscles  the  process  is  known  as 
dystrophy  and  is  often  associated  with  pseudo-hypertrophy  of  the  muscles 
affected. 

Spasm  may  be  (a)  reflex  from  irritation  in  the  region  of  the  muscle,  e.g. 
spasmodic  wry-neck  from  inflamed  cervical  glands,  inflammatory  trismus 
or  lock-jaw  from  an  impacted  wisdom-tooth,  &c. 

(b)  From  over-use,  as  in  the  ordinary  cramp  of  athletic  exercise,  especially 
swimming,  or  in  the  attempts  on  the  part  of  involuntary  muscle  to  overcome 
resistance,  as  in  biliary,  renal,  intestinal,  and  pyloric  colic  or  cramp. 

(c)  From  lesions  of  the  upper  motor  segment  in  brain  and  cord  lesions, 
and  then  associated  with  paralysis  or  paresis. 

(d)  In  functional  affections  of  the  upper  motor  segment,  as  in  writer's 
cramp  and  functional  spasm  and  contracture  of  joints. 

Treatment  of  spasm  is  directed  to  the  cause,  whether  gall-stones  or  teeth 
or  removal  of  pressure  on  the  upper  motor  segment,  as  by  laminectomy  in 
Pott's  disease  of  the  spine.  Functional  spasms  are  considered  in  works  on 
neurology  and  medicine. 

Atrophy  commonly  follows  from  disuse,  whether  due  to  the  muscle 
being  cut  off  from  its  centre  of  innervation,  from  being  retained  on  a 
splint,  from  rest  in  bed  or  from  functional  disuse  ;  less  commonly  atrophy 
may  be  a  sign  of  one  of  the  muscular  dystrophies. 

Atrophy  begins  in  a  diminution  in  size  of  the  muscle-fibres,  which  later 
undergo  fatty  degeneration  till  the  whole  muscle  may  become  a  mass  of 
fat.  In  rare  instances  this  fatty  state  may  cause  the  muscle  to  be  very 
large  but  extremely  weak  (pseudo-hypertrophic  dystrophy).  Where  fatty 
degeneration  is  complete  it  is  doubtful  if  there  is  any  hope  of  the  muscle 
regaining  power  even  if  its  innervation  be  restored. 

Treatment.  When  paralysis  and  atrophy  occur  and  there  is  some 
prospect  later  of  partial  or  complete  recovery,  as  in  infantile  palsy  or  after 
injuries  to  nerves,  these  degenerative  changes  can  be  prevented  to  some 
degree  by  assiduous  daily  massage,  while  at  the  same  time  overstretching  of 


MYOSITIS  421 

the  weak  muscles  should  be  prevented  by  suitable  splints,  walking  instru- 
ments, &c.  For  if  this  overstretching  is  allowed  to  take  place,  deformity- 
will  result,  which  may  be  very  difficult  to  cure. 

Inflammation  of  Muscles.  These  may  be  divided  into  (a)  simple, 
(b)  infective  and  parasitic,  and  (c)  ossifying. 

(a)  Simple  myositis  is  due  to  various  causes  and  clinically  is  found  in 
varying  degrees  of  severity,  from  passing  pain  and  rigidity  to  marked  fibrosis 
and  even  ossification. 

(1)  Traumatic  Myositis.  In  the  initial  stages  there  is  bruising  with 
ecchymosis  into  the  muscle,  which  usually  clears  up,  or  the  effusion  may 
organize  with  fibrosis,  causing  contracture  of  the  muscle,  of  which  type 
ischaemic  contracture  is  an  extreme  degree  (see  Complication  of  Fractures 
and  Injuries  of  Muscles,  p.  225)  ;  in  other  cases  ossification  may  follow  (see 
below,  Myositis  Ossificans). 

(2)  Rheumatic  Myositis.  The  term  "  rheumatic  "  is  used  here  in  the 
sense  in  which  it  is  applied  to  certain  obscure  affections  of  joints.  Cold 
and  damp  appear  to  be  causes,  but  probably  subacute  infections  and  intoxi- 
cations are  of  importance  in  the  production  of  these  conditions,  whether 
from  tonsillar,  appendical,  alimentary,  or  influenzal  origin.  The  affection 
is  marked  by  pain,  tenderness,  and  rigidity  of  the  muscles  (muscular  rheu- 
matism), which  may  be  transient ;  in  the  more  prolonged  examples  nodular 
masses  may  be  felt  in  the  muscles  (Telling  describes  this  later  condition 
as  "  nodular  fibro- myositis  ").  Various  muscles  are  affected,  the  lumbar 
region  being  a  favourite  place,  but  the  abdominal  muscles  are  also  affected, 
and  the  pain  and  rigidity  may  cause  a  mistaken  diagnosis  of,  for  example, 
appendicitis  to  be  made. 

Treatment.  Local  counter-irritants  such  as  blistering  may  benefit  the 
case,  but  massage  and  graduated  exercise  is  the  best  method  of  removing 
these  painful  infiltrations  from  the  muscles. 

(b)  Of  the  definitely  infective  varieties  of  myositis  we  find  : 

( 1 )  Acute  pyogenic  myositis  occurring  as  part  of  ordinary  acute  abscess- 
formation. 

(2)  Tuberculous  myositis,  due  to  invasion  from  neighbouring  tuberculous 
foci,  e.g.  of  the  sternomastoid  from  caseating  glands  of  the  neck,  or  the 
psoas  from  caries  of  the  lower  dorsal  and  lumbar  spine.  The  muscle  dis- 
integrates into  chronic  pus,  its  function  is  diminished,  spasm  being  the  rule — 
followed  by  contracture,  due  to  fibrosis,  as  the  lesion  heals  ;  later,  calcifica- 
tion in  such  abscesses  is  common. 

(3)  Syphilitic  myositis  occurs  in  the  tertiary  stage  and  is  usually  gum- 
matous, less  often  a  diffuse  fibrosis  taking  place.  The  tongue,  masseter, 
and  sternomastoid  are  places  of  election  for  this  affection.  A  swelling  of 
the  muscle  appears,  the  latter  being  in  a  state  of  spasm  ;  soon  the  gumma 
breaks  down  and  often  tracks  to  the  surface,  bursting  through  the  skin 
and  giving  the  characteristic  appearance  of  a  punched-out  ulcer  with  yellow, 
sloughy  contents. 

Diagnosis  is  to  be  made  from  new  growth  ;  the  history.  Wassermann 


122  \  TEXTBOOK  OF  SURGERY 

reaction,   and   effect    of    antisyphilitic    remedies    will    soon    make    this 
olear. 

(4)  Parasitic  myositis  from  trichinia  and  hydatids  only  requires  mention. 

(<■)  Myositis  Ossificans.  The  inflammatory  nature  of  this  curious  disease 
ia  by  no  means  certain  :  it  might  be  equally  well  regarded  as  a  form  oi 
new  growth  or  heteroplasia. 

The  disease  occurs  in  two  forms  :  (1)  the  progressive  ;  (2)  the  traumatic. 

(1)  The  progressive  type  is  probably  of  congenital  origin,  and  consists 
of  an  ossification  of  the  connective  tissue  of  the  muscles  with  atrophy  of  the 
mnsele-tibres.  The  muscles  of  the  trunk,  especially  the  erector  spinse,  are 
primarily  affected,  but  there  is  a  gradual  spread  to  the  muscles  of  the  limbs. 
The  disease  starts  in  boyhood,  being  usual  in  males,  and  slowly  progresses 
for  thirty  or  forty  years  with  periods  of  exacerbation  and  quiescence,  the 
patient  gradually  becoming  very  helpless.  Pathology  and  treatment  are 
alike  unknown. 

(2)  Formation  of  bone  in  muscle  may  follow  one  severe  injury  such  as 
a  fracture  or  dislocation,  or  result  from  repeated  small  injuries,  such  as 
bruising  the  deltoid  with  the  rifle  by  soldiers  or  overstraining  the  adductors 
of  the  thigh  in  riding,  causing  "  drill  "  and  "  rider's  "  bones. 

In  the  type  occurring  with  fracture  or  dislocation  there  is  probably  some 
raising  of  periosteum  with  subperiosteal  haemorrhages ;  the  new  bone 
which  is  formed  invades  the  muscle  in  an  irregular  manner.  These  bony 
outgrowths  may  seriously  affect  the  movement  of  neighbouring  joints. 
This  condition  is  most  common  in  the  brachialis  anticus  and  the  quadriceps 
fenioris.  Treatment  is  not  satisfactory,  as  if  removed  the  growth  tends 
to  recur. 

Neoplasms.  These  hardly  ever  occur  in  the  proper  substance  of  muscle, 
but  a  great  variety  take  origin  from  the  connective  tissue  in  and  around 
muscles,  especially  from  the  surrounding  fascia.  Such  tumours  are  usually 
of  the  connective-tissue  varieties,  one  of  the  commonest  types  being  a 
spindle-celled  sarcoma  of  slow  growth  and  low  malignancy  growing  from 
aponeuroses,  often  from  the  sheath  of  the  rectus  abdominis,  and  then 
called  a  recurrent  fibroid  or  "  desmoid  tumour."  Secondary  sarcomas  and 
carcinomas  also  occur. 

AFFECTIONS    OF   TENDONS    AND   THEIR   SHEATHS   (TENOSYNOVITIS) 
[nfl animation  of  tendons,  both  acute  and  chronic,  are  common:    the 
tendon   is  practically   never   affected  alone,  without  the   sheath,  though 
tions  of  the  sheath  may  be  marked  with  but  a  little  alteration  of  the 
lined  tendon.    Tenosynovitis  may  be  divided  into  acute,  including 
(a)  simple  and  (b)  suppurative  ;  chronic,  which  includes  (1)  simple,  (2)  tuber- 
culous (3)  syphilitic,  and  (4)  ganglia. 

{«)  Simple  Acute  Tenosynovitis.     This  affection  is  generally  due    to 

overuse  of  the  tendons  affected,  as  from  rowing  or  mangling  in  the  case 

of  the  flexor  tendons  o\  the  wrist,  or  walking  in  that  of  the  tendo  Achillis. 

bly  a  diathetic  element   may  play  some  part,  as  some  persons  seem 


TENOSYNOVITIS  -123 

especially  prone  to  these  affections,  but  whether  rheumatism,  gout,  or  other 
constitutional  disease  come  into  play  is  unknown. 

Anatomy.  Hyperemia  of  the  sheath  and  tendon  with  slight  effusion  of 
sticky  plastic  lymph,  which  is  readily  absorbed. 

Signs.  There  is  slight  pain  and  a  feeling  of  weakness  in  using  the 
affected  tendons  ;  the  swelling  from  effusion  may  be  too  slight  to  perceive, 
but  on  grasping  the  part  and  moving  the  joints  controlled  by  the  tendons 
so  as  to  cause  the  latter  to  move  in  their  sheaths  a  fine  grating  will  be  felt 
due  to  the  friction  of  the  roughened  tendon  in  its  sheath,  the  roughness  of 
tendon  and  sheath  being  due  to  the  congestion  and  exudation  of  lymph  on 
the  apposed  surfaces. 

Treatment.  Firm  pressure  over  the  part  by  bandage  or  strapping  ;  in 
more  severe  cases  rest  by  splinting  may  be  needed  for  a  few  days,  and, 
followed  by  massage  and  gentle  exercise,  will  effect  speedy  cure,  but  some 
cases  persist  and  become  chronic. 

(b)  Acute  Suppurative  Tenosynovitis.  This  is  of  pyogenic  origin 
and  results  from  infected  wounds  of  the  sheaths  or  spread  from  neighbouring 
abscess,  cellulitis,  or  acute  bone  disease.  The  tendon-sheaths  become 
hyperaemic  and  soon  filled  with  pus,  and  there  is  considerable  danger  of 
the  tendon  sloughing  if  the  pus  be  not  evacuated  immediately,  since  the 
nutrition  of  tendons  is  soon  seriously  affected  owing  to  the  poverty  of  their 
blood-supply.  The  common  site  for  this  affection  is  in  the  flexor  sheaths 
of  the  fingers,  palm,  and  wrist  (thecal  whitlow).  The  great  pain,  swelling 
of  the  sheath,  inability  to  move  the  joints  over  which  the  tendons  run,  the 
fever  and  constitutional  depression,  render  diagnosis  easy. 

Treatment.  Free  and  early  opening  of  the  sheath  is  needed  to  save  the 
tendon,  followed  by  irrigation  with  dilute  lysol  (minims  15  to  the  pint)  or 
normal  saline  baths  and  fomentations,  while  later  persistent  massage, 
passive  and  active  movements  are  needed  to  prevent  stiffness  of  the  joints 
from  adhesions  of  the  tendon  in  its  sheath.  If  the  tendon  sloughs  away 
some  form  of  plastic  operation  or  tendon-grafting  may  be  effective. 

Chronic  Tenosynovitis.  (1)  Simple  chronic  tenosynovitis  may  follow 
the  acute  affection  or  develop  quietly  from  repeated  overstraining  of  the 
part.  The  tendon-sheath  becomes  slightly  congested  and  distended  with 
glairy  fluid,  sometimes  containing  small  ovoid  masses  of  fibrin  (melon  - 
seed  bodies).  Some  cases  of  this  sort  either  develop  into  tuberculosis 
of  the  sheath  or  are  really  a  very  chronic  example  of  this  infection  from 
the  start. 

(2)  Tuberculous  Tenosynovitis.  This  may  be  (a)  very  chrome,  with 
grey  tubercles  on  the  inner  surface  of  the  sheath  and  effusion  into  the  cavity, 
possibly  containing  melon-seed  bodies  ;  or  (6)  the  sheath  may  be  lined  with 
tuberculous  granulation  tissue  and  there  is  considerable  exudation  of  turbid 
fluid  containing  curds  or  cheesy  material,  and  the  infection  tends  to  spread 
to  neighbouring  parts  such  as  the  bones,  or  to  burst  through  the  skin, 
forming  a  typical  tuberculous  sinus.  In  both  forms,  especially  the  latter, 
melon-seed   bodies   formed    of  organizing   fibrin   are   found.     The   former 


124 


A  TKX'I BOOK  OF  SURGERY 


corresponds  to  the  ascitic,  the  latter  to  the  ulcerative,  form  of  tuberculous 
peritonitis,  the  latter  being  tin-  more  aggressive. 

Syphilitic  tenosynovitis  may  occur  as  a  gummatous  formation  like 
that  affecting  the  synovial  membrane  of  joints  or  bursae. 

(h  Ganglia.    This  somewhai  vague  term  is  applied  to  fluid  or  semi- 
fluid Bwellings  arising  in  the  vicinity  of  joints  and  tendons,  the  origin  of 

wli ich   is   not    always  well 
assured. 

(a)  Simple  ganglia  oc- 
cur usually  on  the  back 
of  the  wrist  as  rounded, 
tensely  fluctuating  swell- 
ings which  are  painless  but 
cause  a  feeling  of  weak- 
ness when  the  hand  is 
used  for  grasping.  These 
swellings  may  be  hernial 
protrusions  from  the  joint 
or  tendon  sheaths,  con- 
taining fluid  ;  in  other 
instances  they  consist  of 
gelatinous  material  con- 
taining a  few  branching 
cells,  when  they  are  to 
be  regarded  as  a  form  of 
colloid  or  myxomatous  de- 
generation of  the  chroni- 
cally inflamed  sheaths. 
Most  cases  are  probably 
mild  inflammations  from 
repeated  slight  injuries  due 
to  overuse  of    the   hands 


Fig.  169.    Compound  palmar  ganglian.    Note  the  swel- 
ling in  the  wrist  and  in  the  palm  which  communicates 
undei  the  annular  ligament. 


in  grasping.     They  are  also  found  aboui  the  ankle. 

(b)  Very  similar  swellings  are  found,  especially  over  the  extensor  tendons 
of  the  thumb,  and  are  due  to  chronic  tuberculous  synovitis.  They  are  like 
the  simple  form  in  texture  but  more  elongate  in  shape,  and  map  out  the 
tendon-sheath  with  considerable  accuracy. 

(r)  Closely  allied  to  the  last  form  is  the  compound  palmar  ganglion, 
which  is  an  affection  of  the  sheaths  of  the  flexor  tendons  at  the  wrist  as 
they  pass  under  the  anterior  annular  ligament.  Some  or  all  of  the 
sheaths  may  be  involved,  and  as  the  sheaths  extend  above  the  ligament 
into  the  forearm  and  below  it  into  the  palm  the  effusion  assumes  an 
hour-glass  shape,  being  constricted  by  the  ligament  in  the  middle,  so 
that  fluctuation  from  the  swelling  in  the  palm  to  that  in  the  forearm 
is  readily  obtained.  The  condition  is  usually  due  to  one  of  the  forms  of 
tuberculous    tenosynovitis    mentioned    above,  though  it   is  possible   that 


GANGLIA.     TENOTOMY  425 

trauma    may  occasionally  be  the  cause.      Melon-seed    bodies  are  present 
in  large  quantities. 

Diagnosis.  The  smaller  ganglia  may  be  taken  for  exostoses,  being  very 
tense,  but  their  position  and  the  fluctuation  will  generally  prevent  this 
mistake  ;  in  a  doubtful  case  a  radiograph  will  make  matters  clear.  When 
invading  the  superficial  structures  the  condition  may  resemble  a  new  growth. 
Treatment  of  Ganglia  and  Chronic  Tenosynovitis.  The  smaller 
ganglia  on  the  dorsum  of  the  wrist  may  be  burst  by  firm  pressure  with  the 
thumbs,  and  sometimes  will  not  appear  again,  but  if  they  recur  or  cannot 
be  burst  {i.e.  when  colloid)  they  should  be  dissected  out.  The  cases  which 
are  certainly  tuberculous  tenosynovitis  may  be  treated  by  plastic  pressure,  as 
by  strapping  over  Scott's  dressing  and  confining  the  joint  on  a  splint.  If, 
however,  they  do  not  disappear  on  this  treatment,  as  is  often  the  case,  or 
increase  rapidly  and  appear  likely  to  burst  through  the  skin,  operation  will 
be  needed.  The  diseased  synovial  membrane  is  dissected  away,  the  effusion 
and  melon-seed  bodies  evacuated,  and  the  wound  closed  completely,  and 
early  passive  and  active  movements  gently  made  to  prevent  adhesions,  but 
strong  active  movements  are  to  be  avoided  for  several  months.  The 
operation  may  need  repeating  before  cure  is  complete,  and  it  is  important 
to  operate  before  the  skin  is  involved.  The  treatment  of  syphilitic  teno- 
synovitis is  specific. 

Operations  on  Tendons  and  Muscles.  These  comprise  tendon-suture, 
tenotomy  and  tendon-lengthening,  tendon-shortening,  tendon-reinforcement 
and  -grafting. 

Tendon-suture.  When  divided  by  accident  or  at  operation  tendons 
should  be  carefully  sutured  with  chromic  catgut,  the  ends  being  brought 
into  neat  apposition  by  sutures  inserted  close  to  the  ends,  but  before  these 
are  tied  one  or  more  long  "  tension  sutures  "  should  be  inserted  at  some 
distance  from  the  ends  and  tied  to  take  most  of  the  strain,  as  sutures  readily 
cut  out  of  the  parallel  fibres  of  tendons  when  inserted  near  their  ends 
(Fig.  83  (4),  p.  254). 

Tenotomy,  or  division  of  tendons,  is  done  when  these  are  too  short  and 
are  maintaining  some  position  of  deformity.  Sometimes  tenotomy  is  useful 
in  cases  of  fracture  to  relax  muscular  spasm.  Muscles  and  fasciae  are  divided 
in  a  similar  manner. 

Operation.  This  is  usually  done  with  a  small  knife  or  tenotome  and 
subcutaneouslv.  Only  one  knife  is  needed;  this  is  sharp-pointed,  with  a 
cutting  edge  about  one-quarter  of  an  inch  long  and  blade  one-sixteenth  of  an 
inch  wide  (formerly  two  knives  were  used — one  to  puncture  the  skin,  the 
other  blunt-pointed  to  divide  the  tendon  :   this  complication  is  not  needed). 

This  small  tenotome  is  inserted  under  or  over  the  tendon  as  may  be 
convenient  ;  the  latter  is  rendered  taut  by  extending  or  flexing  the  limb, 
and  the  tendon  gradually  cut  through  till  it  is  felt  to  give  way  completely 
with  a  jerk,  leaving  a  gap  in  its  length.  A  dressing  is  applied,  and  later 
suitable  retention  or  walking  apparatus  worn.  The  tendon-sheath  is  only 
in  part  divided  ;    hence  retraction  of  the  tendon  is  limited  and  lymph  is 


t26  A  TEXTBOOK  OF  SUKGEEY 

poured  ou1  between  the  divided  ends  and  shortly  unites  these  by  fibrous 
tissue,  which  soon  contracts,  and  the  shortening  of  the  tendon  will  recur 
unless  retentive  apparatus  be  worn  for  some  years.     This  last  is  a  most 
ii.il  feature  in  treatment  of  deformities  by  tenotomy. 

Where  there  are  important  structures  in  the  immediate  proximity  of 
the  tendon  to  be  divided,  as  the  external  popliteal  nerve  in  the  case  of  the 
biceps  temoris  or  the  large  vessels  of  the  neck  in  the  case,  of  the  sterno- 
mastoid  muscle,  subcutaneous  tenotomy  is  contra-indicated  and  the  muscle 
or  tendon  is  exposed  by  open  operation  and  dissection  and  divided  under 

guidance  <>i  vision. 

Where  contraction  of  the  reunited  tendon  or  muscle  is  likely  to  occur, 
as  in  cases  of  spastic  paralysis,  it  will  be  better  to  excise  a  portion  of  the 
regaining  structure  rather  than  to  simply  divide  it;  this  applies  chiefly 
to  the  adductors  of  the  thigh.     Tendons  in  such  cases  are  best  lengthened. 

Tendon  Lengthening.  This  is  done  instead  of  simple  tenotomy  where 
several  tendons  lying  together  require  to  be  elongated,  as  at  the  wrist  in 
cases  of  ischemic  contracture  of  the  muscles  of  the  forearm  or  in  cases  of 
spastic  paralysis,  in  which  simple  tenotomy  is  generally  insufficient. 

The  most  practical  method  of  lengthening  tendons  is  by  the  Z-operatioti. 

The  tendon  is  split  lengthways  and  cut  half  through  at  either  end  of  this 

split  in  opposite  directions  ;    the  flaps  thus  made  of  half  the  thickness  of 

the    tendon    are    then   sutured,    with  a    suitable    amount    of   overlapping 

!■•  ..  83  (3),  p.  254). 

Tendon-shortening  is  needed  in  some  instances  where  the  tendon  has 
become  slack  and  overlong  from  overstretching  of  a  temporarily  paralysed 
muscle  ;  the  tendon  may  lie  divided  obliquely  and  the  ends  made  to  overlap 
to  a  suitable  amount. 

Tendon-suturing,  when  a  portion  of  the  tendon  is  missing  so  that  a  gap 
results  and  the  ends  cannot  he  brought  together  without  undue  tension  or 
not  at  all,  is  m  maged  in  various  ways  :  (1)  A  flap  of  half  tin1  tendon  maybe 
turned  up  from  each  end  and  thus  the  tendon  lengthened  sufficiently. 
(2)  If  two  tendons  run  parallel  and  close,  as  in  the  flexors  of  the  fingers,  and 
a  pari  of  one  only  is  lost,  a  portion  of  the  intact  tendon  may  be  used  to 
bridge  over  the  gap  in  the  affected  tendon  (Fig.  83  (I.  2).  p.  254). 

Tendon  Reinforcement.  Musch-  and  tendon-grafting  or  anastomosis 
{tenoplasty).  The  tendon  of  a  weak  or  paralysed  muscle  may  be  strengthened 
by  attaching  to  it  the  tendon  of  a  neighbouring  healthy  muscle.  It  is 
best  to  select  for  this  purpose  a  muscle  having  the  same  sort  of  action  as 
the  one  which  needs  reinforcement.  Thus  a  weak  tiabilis  anticus  may  he 
strengthened  by  portions  of  the  tendons  of  the  dorsal  extensors  of  the 
great  foe  and  other  Iocs.  A  portion  of  the  tendons  of  these  muscles  is 
Butured  carefully  into  the  weak  tendon.  As  the  weak'  tendon  is  liable  to 
become  si  retched,  it  is  probably  better  to  insert  the  reinforcing  slip  info 
it-  periosteal  attachment  as  well,  to  get  a  stronger  attachment.  In  some 
instances  the  action  of  a  muscle  has  been  reversed  in  this  way  by  altering 
the  attachment.     Thus  the  pronator  radii  teres  has  been  detached  from 


AFFECTIONS  OF  BURS.E  427 

its  radial  insertion  and  passed  round  the  back  of  the  radius  and  again  sutured  in 
position,  thus  converting  its  action  into  that  of  a  supinator  in  cases  of  supinator 
paralysis.  Much  training  is  needed  to  secure  success  after  such  measures. 
(Fig.  83  (6).) 

AFFECTIONS   OF  BURS^ 

Bursa?,  which  are  cavities  lined  with  synovial  membrane,  exist  normally 
over  bony  prominences  and  between  the  origins  and  insertions  of  muscles 
to  diminish  friction  ;  they  also  occur  as  "  adventitious  bursa?  "  at  places 
where  foreign  bodies  rub  against  bony  prominences,  as  on  the  head  or 
shoulders  of  porters,  and  over  abnormal  points  of  bone,  as  in  the  deformed 
tarsus  of  club-foot,  and  over  exostoses.  Bursa?  may  be  affected  with  acute 
or  chronic  inflammation. 

Acute  Bursitis  may  be  simple  or  suppurativa.  (a)  Simple  acute 
bursitis  may  be  due  to  single  or  repeated  injuries,  the  bursa  filling  with 
serum,  lymph  or  blood.  The  bursa  becomes  painful,  tender,  swollen  and 
fluctuating,  warm  to  feel,  and  perhaps  red.  If  kept  at  rest  the  condition 
usually  subsides,  especially  if  firm  pressure  with  strapping  be  made  over 
the  swelling,  but  infection  may  at  any  time  arise  in  such  a  bursa  and  sup- 
puration take  place,  the  inflammation  becoming  more  acute,  the  skin  red 
and  purplish,  while  fever  and  other  signs  of  toxa?mia  are  noted. 

(b)  Suppurative  bursitis  may  be  the  ending  of  the  simple  variety  or 
may  come  on  spontaneously,  infection  being  usually  with  streptococci  or 
pneumococci.  The  signs  are  those  of  acute  abscess,  the  skin  being  red, 
changing  to  purple,  swollen,  cedematous,  and  boggy  ;  great  pain,  tenderness, 
and  fluctuation,  as  well  as  general  disturbance,  are  present. 

Treatment.  The  simple  acute  variety  will  usually  subside  on  rest  and 
pressure,  but  if  the  exudation  is  not  absorbed  readily  aspiration  of  this 
should  be  practised.  When  suppuration  takes  place  the  bursa  should  be 
freely  opened  and  drained,  since  if  this  is  neglected  or  inadequately  performed 
there  is  some  risk  of  a  spreading  cellulitis  resulting,  especially  from  infection 
of  the  olecranon  or  prepatellar  bursa. 

Chronic  Bursitis.  A  simple  form  may  arise  from  repeated  injuries  or 
mild  pyogenic  infection  insufficient  to  cause  suppuration  :  it  may  be  due  to 
infection  with  tubercle,  syphilis  or  the  pneumococcus,  or  result  from  gout. 

(a)  Simple  chronic  bursitis  consists  of  a  fibrous  thickening  of  the  wall 
of  the  bursa  with  effusion  of  serum  and  lymph  inside  this,  the  thickening 
and  effusion  varying  in  relative  proportion.  Thus  the  thickening  may  bo 
great  with  but  little  effusion,  when  the  condition  is  described  as  "  fibroid," 
or  the  effusion  may  be  extensive  with  but  little  fibrosis  :  melon-seed  bodies 
and  papillary  outgrowths  from  the  walls  may  be  found.  Where  fibrosis  is 
groat  the  bursa  may  be  of  cartilaginous  hardness  and  even  calcified. 

Diagnosis.  This  is  usually  simple  ;  there  will  be  a  rounded  tumour 
more  or  less  fluctuating,  in  the  position  where  bursa?  are  usual,  with  a 
history  of  considerable  variations  in  size  and  discomfort. 

Treatment.  Where  the  contents  are  liquid  and  the  wall  thin,  aspiration 
followed  by  firm  pressure  with  strapping  may  be  used,  but  relapses  are 


128  A  TKXTBOOK  OF  SURGERY 

somewhat  common,  and  should  these  occur,  or  in  cases  where  the  bursal  wall 
is  thick  and  fibrous,  removal  by  dissect  ion  is  the  besl  treatment. 

(b)  Tuberculous  bursitis  may  occur  in  a  very  chronic  form  with  fibrosis 
of  the  wall  and  effusion  and  melon-seed  bodies  in  the  cavity,  or  may  be 
subacute  with  formation  of  much  granulation  tissue  and  a  tendency  to 
invade  surrounding  structures  and  burst  through  the  skin  (as  in  tuberculous 
tenosynovitis). 

Treatment.  The  milder  cases  may  subside  on  rest,  strapping,  and 
aspiration  of  the  contents,  but  if  advancing  they  should  be  dissected  out 
if  practicable  or  the  granulation  tissue  carefully  scraped  away  and  the 
cavity  closed  with  drainage  for  twenty-four  hours,  as  in  other  cold  abscesses. 

(c)  Pneumococcal  bursitis  may  be  of  chronic  nature,  containing  the 
thick  yellow  pus  with  clotted  lymph  like  other  infections  due  to  this  organism. 
Where  extensive  these  may  be  very  difficult  to  cure  by  incision  and  drainage  ; 
the  use  of  vaccines  is  worth  a  trial. 

(d)  Syphilitic  bursitis  is  not  uncommon  in  the  form  of  subcutaneous 
gummata  occurring  in  the  position  of  a  bursa.  These  tend  to  break  down 
and  penetrate  the  skin,  forming  the  well-known  gummatous  ulcer. 

(e)  Gouty  bursitis  is  also  described  in  the  form  of  a  deposit  of  urates 
in  bursse,  which  form  "  chalk  stones." 

AMPUTATIONS  OF  THE  LIMBS 

The  term  amputation  usually  implies  the  removal  of  the  whole  or  part 
of  one  of  the  extremities,  but  is  also  applied  to  the  removal  of  such  organs 
as  the  breast  or  penis. 

Where  the  point  of  section  is  through  a  joint  the  process  is  sometimes 
known  as  resection  or  disarticulation. 

In  modern  civil  practice  amputations  form  a  very  small  part  of  surgical 
operations,  and  with  improved  conservative  methods  become  ever  less  and 
less  necessary — which  is  most  desirable,  since  amputation  is  a  confession 
of  defeat  on  the  part  of  the  surgeon. 

General  Considerations.  (1)  The  Place  at  which  to  Amputate.  This 
depends  on  the  condition  rendering  amputation  necessary.  Thus  in  accident 
cases  we  may  amputate  immediately  above  the  portion  of  the  limb  destroyed. 
In  chronic  infective  conditions  also  it  is  safe  to  divide  the  limb  fairly  close 
to  diseased  structures.  When  amputation  is  done  for  acute  infections  or 
malignant  disease,  or  where  there  is  vascular  degeneration  present,  the 
margin  of  safety  must  be  wider  ;  thus  in  gangrene  of  the  foot  from  vascular 
causes  amputation  in  the  lower  thigh  will  usually  be  needed. 

The  age  of  the  patient  affects  the  place  and  type  of  amputation.  In 
young  subjects,  who  heal  readily,  an  amputation  may  be  complicated  by 
plastic  operation  on  the  bones  to  secure  a  better  stump  ;  such  complications 
should  be  avoided  in  the  aged,  whose  powers  of  recovery  are  less.  Again, 
in  the  young  the  limb  will  continue  to  grow  and  push  its  way  through  the 
end  of  the  stump  unless  its  covering  is  very  ample  ;  hence  good  large  flaps 
are  specially  needed  in  the  young. 


AMPUTATIONS  :    GENERAL  CONSIDERATIONS  429 

Points  to  be  considered  in  the  formation  of  a  serviceable  stump.  There 
will  be  some  difference  in  the  two  limbs. 

(a)  In  the  lower  limb  a  firm  stable,  weight- bearing  stump  is  needed, 
and  weight  can  only  be  taken  directly  on  the  face  of  the  stump  in  tw,o 
situations,  viz.  at  the  lower  end  of  the  leg  on  the  integuments  of  the  heel 
(Syme's,  Pirogoffs,  or  the  subastragaloid  amputation)  and  at  the  knee 
(Stephen  Smith's,  Stoke's,  or  G-ritti's  amputations),  and  in  such  case  care 
is  needed  that  the  scar  is  not  at  the  end  of  the  stump.  In  other  situations 
the  bearing  surface  for  the  artificial  limb  is  the  tuber  ischii  or  the  tuberosities 
of  the  tibia,  according  as  the  section  of  bone  is  above  or  below  the  knee- 
joint. 

(b)  In  the  upper  lirnb  freedom  of  movement  is  more  important  than 
strength  :  hence  the  stump  should  be  made  as  long  as  possible  and  move- 
ments preserved  where  possible,  e.g.  pronation  and  supination  by  preserving 
the  attachment  of  the  pronator  radii  teres  to  the  radius,  elbow  movements 
by  preserving  as  much  forearm  as  possible,  and  abduction  of  the  arm  by 
leaving  the  deltoid  insertion ;  also  by  suturing  the  tendons  where  divided 
to  the  ends  of  the  stump  to  assist  in  preserving  their  actions. 

In  all  cases  the  main  nerves  of  the  limb  should  be  dissected  up  some 
inches  and  excised  to  avoid  the  formation  of  painful  bulbs  on  their  ends, 
which  is  likely  to  occur  if  they  are  left  long  and  become  involved  in  the 
cicatrix. 

Careful  asepsis  is  needed  in  amputations  as  in  other  operations,  for 
infection  of  the  tissues  of  the  stump  will  probably  lead  to  necrosis  of  the 
end  of  the  bone,  followed  later  by  adherence  of  the  scar  to  the  bone,  which 
is  usually  a  cause  of  painful  stump  ;  or  sloughing  of  the  flaps  may  result, 
causing  their  restriction  from  the  bone  and  formation  of  a'-  conical  stump." 

Conical  stumps  may  also  be  the  result  of  cutting  the  flaps  too  short,  and 
the  beginner  will  do  well  to  allow  for  the  covering  of  the  bone  at  least  half 
as  much  again  as  would  seem  to  be  necessary  :  flaps  can  hardly  be  too  long. 
In  young  subjects  "  conical  stump  "  may  be  due  to  the  constant  lengthening 
of  the  bone  causing  pain  in  the  stump  and  perhaps  ulceration  and  adherence 
of  the  bone.  The  only  treatment  for  this  condition  is  to  resect  the  end 
of  the  bone  for  some  inches. 

Technique  of  Amputations.  There  are  to  be  considered  (a)  control 
or  haemorrhage  ;  (b)  the  position  of  the  operator  ;  (c)  methods  of  dividing 
soft  tissues  and  bones  ;    (d)  terminal  steps  of  the  operation. 

(a)  Control  of  Hemorrhage.  For  amputations  below  the  hip  or  shoulder 
the  simplest  plan  is  to  use  the  elastic  tourniquet,  which  consists  of  a  stout 
rubber  tube  with  a  hook  attached  at  one  end  and  a  chain  at  the  other  to 
fasten  it  when  applied.  Any  stout  rubber  tube  of  adequate  length  will, 
however,  suffice,  and  after  tightening  it  may  be  tied  in  a  single  hitch  and 
this  secured  with  a  pair  of  large  clamp-forceps. 

To  apply  a  tourniquet  the  limb  is  held  for  a  minute  in  the  vertical  posi- 
tion to  drain  off  the  venous  blood  ;  a  sterile  towel  is  placed  round  the 
limb  to  protect  the  skin,  the  tourniquet  i-<  passed  on  the  far  side  of  the  limb 


130  \  fEXTBOOE  OF  SURGERY 

l>\  the  assistant  who  is  applying  it,  then  strained  taut,  wound  round  the 
limb  and  fastened.  A  little  practice  is  Deeded  to  do  this  effectively 
enough  to  check  arterial  as  well  as  venous  bleeding,  since  if  the  latter  alone 
be  obstructed  bleeding  is  made  considerably  worse  than  if  no  tourniquet 
were  applied.  To  secure  adequate  application  of  the  tourniquet  the  limb 
should  be  held  firmly  by  sonic  other  person  than  the  one  applying  the 
instrument.  For  amputations  of  the  arm  or  forearm  the  tourniquet  may 
be  applied  just  below  the  axilla,  while  in  the  lower  limb  the  upper  part  of 
the  thigh  is  the  place  for  application. 

( tther  methods  for  rendering  an  amputation  bloodless,  such  as  temporary 
ligature  or  clamping  the  main  vessel,  preliminary  ligature  and  holding  the 
ils  in  the  lap  when  it  is  partially  cut,  are  described  under  Amputations 
of  the  Hip  and  Shoulder. 

(6)  Position  of  the  Operator.  The  general  rule  is  for  the  surgeon  to 
stand  with  the  left  hand  to  the  Haps  and  the  right  to  the  part  to  be  removed  ; 
in  other  words,  the  surgeon  stands  on  the  patient's  right  side  of  the  limb  to 
be  amputated,  between  the  head  and  the  arm  for  the  right  arm,  to  the 
right  of  the  right  leg,  between  the  legs  for  the  left  leg,  and  between  the 
arm  and  body  for  the  left  arm.  Exceptions  to  this  rule  are  in  amputa- 
tions about  the  ankle  and  tarsus  :  here  the  surgeon  sits  and  faces  the 
sole  to  cut  the  plantar  flap  and  marks  the  prominences  which  limit 
the  bases  of  the  flaps  (malleoli,  tubercle  of  the  saphoid,  or  base  of  the 
fifth  metatarsal,  according  to  the  amputation  to  be  performed)  with  the 
left  forefinger  and  thumb,  held  in  the  pronated  position  so  that  the 
finger-tip  is  on  the  bony  landmark  to  the  right  of  the  operator,  while  the 
thumb  is  on  that  to  his  left.  In  other  amputations  the  skin  may  be 
steadied  in  a  similar  manner. 

(c)  Methods  of  Dividing  Tissues.  The  simplest  plan  is  to  divide  all  soft 
parts  dowu  to  the  bone  in  a  circular  manner  and  then  retract  the  skin  and 
muscle  by  sliding  it  upwards  as  much  as  possible,  and  again  cut  through  the 
base  of  the  cone  of  muscle  thus  laid  bare  in  a  circular  manner  at  right- 
angles  to  the  axis  of  the  limb.  This  manoeuvre  may  be  repeated  again  if 
necessary.  In  this  manner  a  hollow  cone  of  muscle  and  integuments  is 
formed  to  cover  the  bone.  This  plan  of  "  circular  "  amputation  is  simple 
and  satisfactory  where  the  limb  is  of  equal  diameter  for  some  distance, 
as  in  the  arm  or  the  forearm  above  the  wrist ;  but  where  the  limb  is  conical, 
as  in  the  forearm  high  up  and  in  the  calf  or  thigh,  the  sliding  of  the  super- 
ficial tissues  will  not  be  satisfactory. 

The  "  oval  "  or  "  elliptical "  method  is  a  modification  of  the  last,  and 
is  useful  where  on  one  aspect  of  the  limb  the  soft  parts  retract  much  more 
than  on  the  other  ;  e.g.  owing  to  the  retraction  of  the  biceps  the  lower  end 
of  the  oval  will  be  in  front  in  the  arm,  while  in  the  thigh,  owing  to  the 
iction  of  the  biceps  sinus,  this  should  be  behind.  The  circular  and 
oval  methods  have  the  disadvantage  of  bringing  the  scar  over  the  end 
of  the  Btump  which,  however,  is  only  of  consequence  if  weight  is  to  be 
taken  on  the  face  of  the  stump,  and  this  can  only  be  done  in  certain  situa- 


AMPUTATIONS  :    GENERAL  CONSIDERATIONS 


i:;i 


tions,  viz.  at  the  ankle  and  knee,  henc  ■  at  these  places  flap  methods  are 
always  used. 

The  "  racket  incision  "  is  a  circular  or  oval  incision  with  a  longitudinal 
cut  added  at  one  part  of  its  circumference,  and  is  convenient  for  dissecting 
up  soft  parts,  especially  where  the  part  to  be  removed  is  of  much  less  diameter 


Pro.   170.     Amputations.     1,  Circular,  showing  line  of  division  of  skin  and  muscle. 
II,  Unequal  flaps.     Ill,  Racquet  incision. 

than  the  part  from  which  the  removal  takes  place,  e.g.  amputations  at  the 
hip,  shoulder,  metacarpophalangeal  and  metatarso-phalangeal  joints. 

If  two  longitudinal  incisions  are  made  at  the  opposite  points  of  the 
circumference  of  a  circular  amputation  the  result  becomes  an  amputation 
by  equal  flaps,  which  may  be  antero -posterior  or  lateral  or  in  some  inter- 
mediate position. 

The  "  flap  "  method  (and  by  this  is  usually  meant  unequal  flaps)  is 
employed  to  obtain  a  cicatrix  away  from  the  bearing  surface  of  the  stump, 
especially  at  the  knee  or  ankle  or  where  the  disease  or  injury  extends  more 
on  one  aspect  of  the  limb  than  on  the  other.  Flaps  of  equal  length  have  no 
advantage  over  a  circular  incision  except  that  the  soft  parts  are  more  easily 
reflected  by  this  method.     Usually  one  Hap  is  considerably  the  longer  and 


132 


A  TEXTBOOK  <>F  SURGER1 


Is  taken  from  the  aspecl  of  the  limb  where  the  skin  and  other  tissues  are 
tougher  and  more  able  to  take  the  weighl  of  the  superincumbent  body: 

the  disadvantage  of  long,  unequal  flaps  16  I  hat  t  hat  material  may  lie  wasted 
and  the  stump  he  shorter  than  if  the  amputation  were  performed  by  other 
methods  :  hence  (lap  operations  are  less  suitable  for  the  upper  than  the 
lower  limb.  A  veiy  useful  type  of  flap  is  the  osteoplastic,  where  some 
portion  of  bone  is  used  (preferably  one  which  is  \[^<-t\  to  bearing  weight)  to 


Fig.  J71.     Circular  amputation.     A,  Position  at  commencement, 
B,  at  close  of  the  incision. 

form  the  bearing  surface  at  the  end  of  the  stump,  as  in  Stokes's  or  PlrogofPs 
amputation.  Flaps  consist  of  skin,  fat,  and  muscle  ;  there  is,  however, 
no  object  in  having  a  large  amount  of  the  latter,  as  it  will  surely  waste  from 
disuse.  It  is  really  sufficient  to  have  the  skin,  superficial  and  enough  deep 
fascia  to  ensure  a  good  blood-supply  to  the  flap  (hence  the  importance  of 
keeping  the  edge  of  knife  away  from  the  skin  and  removing  deep  fascia 
freely  in  the  flap,  in  exactly  the  opposite  manner  to  that  employed  in 
removing  skin  from  cadavers  in  the  dissecting-room).  The  flaps  should  he 
neatly  square  at  their  ends  or  broadly  U-shaped  and  not  tapering  at  all. 

Length  of  Flaps.  The  combined  length  of  flaps  should  be  not  less 
than  l'  diameters  of  the  limb  (at  the  point  where  the  bone  is  divided), 
and    in    i  es   L'!    diameters   will  be  a  better  allowance.      Circular 

amputations  may  be  regarded  as  made  of  two  equal  flaps,  so  that  in 
these  amputations  the  section  of  the  bone  should  be  a  diameter  of  the  limb 
above  the   skin  incision. 


AMPUTATIONS  :  CUTTING  SOFT  PARTS 


433 


Method  of  Cutting  Soft  Parts.  The  skin  is  always  cut  from  without 
inwards  ;  there  is  no  need  now  to  perform  the  whole  operation  by  trans- 
fixion, as  was  the  case  in  pre-ansesthetic  days,  when  speed  was  the  all- 
important  factor  in  operations. 

To  make  a  circular  incision  a  long  knife  is  passed  below  the  limb 
away  from  the  operator,  then  round  over  the  upper  surface  till  the  edge 
is  on  the  side  next  the  operator,  the  thumb  of  the  hand  which  holds  the 
knife  resting  on  the  upper  surface  of  the  limb.     By  drawing  the  knife  over 


Fig. 


A  B 

172.     A,  Circular  amputation,  retracting  skin  and  muscles  to  divide^muscles 
a  second  time.     B,  Transfixion  of  muscles  after  division  of  the  skin. 


the  limb  away  from  the  operator  and  following  round,  over,  under  and  up 
again  on  the  near  surface,  a  clean  incision  is  made  in  one  cut,  which  if 
necessary  may  pass  right  down  to  the  bone. 

For  cutting  flaps  a  shorter  knife  is  used,  starting  on  either  side,  as  is 
convenient,  and  marking  out  a  flap  of  skin  and  deep  fascia  only,  dissecting 
these  up  till  the  line  for  division  of  the  bone  is  reached,  and  then  cutting 
through  the  muscles  in  a  circular  manner  with  a  long  knife  or  cutting  flaps 
of  muscle  of  similar  shape  but  shorter  to  those  of  skin  and  fascia.  Where 
the  muscles  retract  freely  and  do  not  offer  much  resistance  for  cutting  in 
this  manner  they  may  be  divided  by  transfixion,  passing  the  knife  between 
the  bone  and  muscle  and  cutting  from  within  outwards.  Tendons,  for 
example  in  the  lower  forearm,  are  best  cut  by  transfixion. 

Bone  Section.  The  bone  is  divided  with  a  saw,  taking  care  not  to  splinter 
it  when  nearly  sawn  through  ;  this  is  done  by  altering  the  direction  of 
sawing  through  a  right  angle  when  three-quarters  of  the  way  through,  so 
that  the  strain  is  more  equally  distributed. 


\.\\  A  TEXTBOOK  OF  SURGERY 

Where  the  bone  is  subcutaneous,  e.g.  the  tibia,  if  it  be  sawn  off  squarely 

there  will  be  a  projecting  corner  likely  to  fret  the  adjacent  skin-flap  ;  there- 
fore the  side  next  the  skin  should  be  sawn  through  obliquely  for  half-way, 
starting  above  the  line  of  bone  section,  and  then  by  sawing  squarely  into 
this  cut  the  bone  will  be  bevelled  off  at  the  line  of  section.  The  edges  of 
the  bone  should  be  rounded  off  with  cut  ting-forceps  or  chisel.  There  is  no 
need  to  fashion  flaps  of  periosteum  before  dividing  the  bone.  During  the 
division  of  the  bone  the  soft  parts  are  kept  out  of  the  way  by  a  linen-retractor 
consisting  of  two.  or  for  the  leg  or  forearm  three,  strips  of  linen. 

(d)  Terminal  Steps  of  the  Operation.  The  main  vessels  are  dissected 
up  for  a  short  distance  to  see  that  no  lateral  branches  have  been  cut  close 
to  the  main  line  of  section  and  tied  ;  other  vessels  are  looked  for  in  known 
situations  and  secured.  The  tourniquet  is  removed  and  bleeding-points 
picked  up  and  tied  :  oozing  of  blood  is  checked  by  free  use  of  hot  lotion. 
The  nerves  are  dissected  up  and  divided  high  above  the  bone-section. 

The  muscles  and  tendons  are  sutured  over  the  end  of  the  bone,  especially 
in  certain  situations  where  their  function  is  likely  to  be  useful.  The  skin  is 
united  with  silkworm-gut  or  metal  clips  and  a  drain-tube  inserted  for  twenty- 
four  hours  in  the  larger  amputations,  as  there  is  always  a  considerable 
escape  of  serum  and  blood  from  the  large  raw  surface.  The  stump  is 
covered  with  plenty  of  dressing  and  bandaged  on  a  short  splint  to  prevent 
the  painful  starting  of  the  divided  muscles. 

Artificial  Limbs.  At  least  three  months  should  be  allowed  to  elapse 
before  ordering  an  artificial  limb,  to  give  the  scar  time  to  consolidate  and 
the  muscles  time  to  undergo  atrophy  and  shrinkage,  so  that  the  stump 
assumes  its  permanent  size. 


CHAPTER  XIV 
REGIONAL  SURGERY  OF  THE  SKELETOMOTOR  SYSTEM 

Affections  of  the  Spine  :  Anatomy  and  examination  :  Acute  pyogenic  infec- 
tions :  Tuberculosis  of  the  Spine  :  Syphilis  and  Typhoid  infection  of  the  Spine : 
Rheumatoid  affections  of  the  Spine  :  Static  deformities  of  the  Spine  :  Tumours 
of  the  Spine:  The  Neck:  Cervical  Ribs:  Torticollis:  The  Clavicle,  acute  infec- 
tions :  Xew  growths  :  Excision  of  the  Clavicle  :  The  scapula — congenital 
defects,  winged  scapida  :  Infections  and  tumours  :  Excision  of  the  Scapula  : 
Affections  of  the  shoulder,  flail  Shoulder :  Infections — pyogenic,  tuberculous, 
ankylosis  :  Operations  at  the  Shoulder  :  Amputation  of  the  entire  upper  limb  ; 
The  Humerus — affections  and  amputations  through  :  The  Elbow  :  Tuber  - 
losis — operations  :  The  Forearm— congenital  defects,  infections,  Amputations  : 
The  Wrist :  Tuberculosis — excision :  Deformities  of  the  Hand  and  Fingers  : 
Infection  of  the  Hand  and  Fingers :  Amputation  of  the  Hand  and  Fingers : 
The  Pelvis — infections  and  tumours  :  Interileo-abdominal  amputation  :  The 
Buttock  :  The  Hip — congenital  dislocation,  snapping  hip,  acute  arthritis  : 
Tuberculosis- — rheumatoid  affections,  coxa  vara,  ankylosis,  bursa?  :  Treat- 
ment :  Operations  at  the  Hip  :  The  Femur  :  The  Knee — acute  infection, 
tuberculosis,  operative  treatment :  Deformities  of  the  Knee — genu  varum  and 
valgum  :  Operations  about  the  Knee  :  The  Leg — infections,  tumours,  opera- 
tions :  The  Ankle,  operations  and  amputations  :  Club-foot  :  Flat-foot  :  Hallux 
Valgus,  &c.  :  Paralyses  in  children  and  their  results  :  Operations  on  the  Feet 

and  Toes. 

In  this  section  are  considered  diseases  and  deformities  of  the  bones,  joints, 
muscles,  tendons,  and  bursa?  of  special  regions,  including  the  spine  and 
limbs.  Injuries  of  the  spine  and  cord,  as  well  as  affections  of  nerves,  are 
considered  in  the  section  on  Affections  of  the  Nervous  System. 

The  surgery  of  blood  and  lymphatic  vessels  are  considered  in  a  special 
section. 

AFFECTIONS  OF  THE  SPINE 
(For  Injuries  see  Nervous  System) 

General  Anatomy.  The  spine  may  be  regarded  as  a  jointed,  hollow 
rod  with  varying  possibilities  of  flexion  in  different  parts — greatest  in  the 
cervical  and  lumbar  regions,  less  in  the  thoracic,  and  absent  at  the  sacrum. 
The  spinal  column  serves  the  double  purpose  of  a  protective  covering  for 
the  spinal  cord  and  Cauda  equina  and  of  forming  an  axis  from  which  the 
limbs  take  origin.  It  is  chiefly  from  the  latter  point  of  view  that  the  spine 
is  considered  in  this  section.  Besides  being  jointed  and  springy  from  the 
presence  of  the  elastic  intervertebral  discs,  the  spine  gains  additional  elas- 
ticity from  its  curves,  which  are  normally  in  an  antero-posterior  direction. 
In  the  cervical  region  the  convexity  of  the  curve  is  forward,  in  the  dorsal 

435 


436  \  T FA'I  HOOK  OF  SURGERY 

M  backward,  while  in  fche  lumbar  region  it  is  again  forward,  and  back- 
ward in  the  sacrum.  Excessive  convexity  forward  is  known  as  lordosis, 
while  a  convexity  backward  is  known  as  kyphosis.  Where  there  is  con- 
vexity to  one  or  both  sides,  which  is  never  normal,  the  condition  is  described 
as  lateral  curvature,  lateral  deviation,  or  scoliosis. 
The  following  diseases  are  described  : 

(1)  Inflammations  and  infections,  both  acute  and  chronic. 

(2)  Deformities  apart  from  definite  inflammation  and  due  to  rickets, 
bone-softening  of  adolescents,  and  congenital  defects  (static  deformities). 

(."))  New  growths. 

Examination  of  Spinal  Cases.  The  patient  should  be  examined 
stripped  and  walking,  standing,  sitting,  lying  down,  and  any  deformity  or 
abnormal  gait  noted  :  a  complete  examination  is  needed  in  order  not  to 
miss  the  cause  of  the  condition.  Thus  lordosis  may  be  due  to  congenital 
displacement  of  the  hips,  while  scoliosis  from  shortness  of  one  leg  will 
disappear  when  the  patient  sits  down. 

The  mobility  of  the  spine  should  be  tested  by  making  the  patient  stand 
up  and  try  to  touch  the  toes  while  the  knees  are  extended  ;  this  will  often 
make  a  slight  deformity  more  apparent.  The  limits  of  extension  backwards 
of  the  spine  are  also  tested — in  adults  in  the  sitting  position,  in  children  by 
placing  the  patient  on  the  face  and  raising  the  extended  legs  from  the  couch 
over  the  back  ;  a  great  degree  of  lordosis  is  permitted  by  the  elastic  spine 
of  children.  The  part  where  the  normal  curves  are  deficient  or  the  elas- 
ticity of  the  spine  altered  or  absent  is  noted.  The  vertebrae  are  jarred 
individually  to  find  tenderness  and  the  head  jarred  on  to  the  spinal  column 
to  see  if  tenderness  is  referred  to  any  special  point.  Finally  a  general 
examination  is  made  for  uneven  length  of  the  lower  limbs,  old-standing 
empyema,  rickets,  paralysis  of  the  lower  limbs,  or  loss  of  sphincter-control, 
and  for  the  presence  of  gravitation  abscess  such  as  a  psoas  or  retro-pharyngeal 
abscess. 

(I)  Inflammations  of  the  Spine.    The  following  varieties  are  found  : 

(a)  Acute  pyogenic  infections  (osteomyelitis). 

(b)  Subacute  infections  (tubercle,  syphilis,  enteric). 

(c)  Chronic  rheumatoid  affections. 

(a)  Acute  osteomyelitis  of  the  spine  is  due  to  an  infection  with  pyogenic 
organisms,  usually  staphylococci,  and  is  akin  to  the  juxta-epiphyseal  infec- 
tions of  the  long  bones,  but  is  far  less  common  and  of  very  grave  prognosis, 
having  a  mortality  of  about  60  per  cent. 

There  is  infection  of  the  cancellous  bone  under  the  epiphyseal  line  of 
the  bodies  or  of  the  spines  (more  usual) ;  one  or  more  vertebra?  are 
affected.  Necrosis  rapidly  takes  place  and  subperiosteal  abscesses  form, 
which  may  track  into  the  spinal  canal  or  along  the  attachments  of  the 
muscles  into  the  dorsal  or  lumbal'  regions  or  along  the  psoas  sheath. 

Signs.  The  onset  is  sudden,  with  high  fever,  pain  in  the  back,  and 
often  delirium.  There  is  rigidity  of  the  spine,  but  no  pain  on  jarring  at 
firsl  (in  some  instances  a  history  of  injury  may  be  obtained).     The  spread 


OSTEOMYELITIS  OF  THE  SPINE 


437 


of  pus  into  the  muscles  may  cause  flexion  of  the  thigh  when  the  psoas  is 
affected,  or  the  appearance  of  a  deep-seated  abscess  of  the  lumbar  region 
which  if  unilateral  may  cause  lateral  curvature  of  the  spine  ;  if  the  exudation 
extends  into  the  spinal  canal  there  will  be  nerve-root  pains  and  paraplegia 
of  the  upper  segment  type. 

Diagnosis.  This  may  not  be  easy.  The  pain  may  be  referred  to  the 
abdomen,  wThich  may  also  appear  distended,  but  the  fades  will  not  be 
that  of  acute  abdominal  disease,  nor  will 
there  be  abdominal  tenderness  and  resist- 
ance nor  intestinal  obstruction.  The 
absence  of  signs  in  the  lungs  and  the 
character  of  respiration  will  negative 
lung  disease.  The  diagnosis  from  menin- 
gitis has  to  be  considered,  especially  as 
the  spread  of  pus  may  later  involve  the 
meninges.  The  localized  nature  of  the 
rigidity  and  absence  of  retraction  of  the 
head  and  the  tender  swelling  in  the  lum- 
bar region  will  be  against  meningitis, 
while  flexion  of  the  hip  from  invasion  of 
the  psoas  will  be  a  valuable  sign. 

Treatment.  Operation  is  urgently 
needed ;  the  area  of  greatest  tender- 
ness and  rigidity  should  be  explored 
by  a  median  dorsal  incision,  examining 
the  spines  and  lamina?,  and  if  these 
are  normal,  opening  the  spinal  canal 
(laminectomy)  and  exploring  the  ex- 
tradural space.  If  nothing  is  found 
here  the  bodies  should  be  investigated 
through  the  same  incision,  or  if  the 
psoas  is  clearly  affected  exploration 
may  be  made  in  the  loin  as  in  renal 

surgery  and  the  transversalis  fascia  pushed  forwards  with  the  kidney, 
dissecting  inwards  till  the  psoas-sheath  is  reached  and  opening  this  till  the 
diseased  vertebras  are  reached,  removing  as  much  necrosed  bone  as  possible 
and  establishing  free  drainage  :  later  sequestra  may  need  removal. 

(b)  Subacute  and  chronic  diseases  of  the  spine  include  syphilis,  tuber- 
culosis, enteric,  and  gonorrhoea!  infections — the  first  being  by  far  the  most 
common  and  important. 

(1)  Tubeeculosis  of  the  Spine  (spinal  caries,  Pott's  disease).  This  is 
dueto  infection  of  the  vertebra?  with  the  tubercle  bacillus,  which  arrives  via 
the  blood-stream.  The  bodies  are  usually  affected,  less  often  the  spines 
or  lamina?.  A  history  of  injury  is  often  given,  and  this  is  probably  respon- 
sible in  some  cases,  causing  a  place  of  lowered  resistance  where  the  bacilli 
more  readily  attain  lodgement. 


Fig.    173.      Tuberculosis  of  the  dorsal 
spine  with  severe  angular  kyphosis. 


m 


A  TEXTBOOK  OF  SURGERY 


The  disease  is  most  common  in  childhood  but  not  uncommon  in  young 
adults,  and  may  affect  any  pari  of  the  spine  above  the  sacrum:  the  dorsal 
region  is  the  place  of  election  for  this  disease. 

ia  mentioned  above,  thedisease  takes  origin  usually  in  the  bodies  of  one 
or  more  vertebra;  less  often  in  the  spines, laminae, or  articular  processes. 
The  process  is  one  of  caries  of  t  he  cancellous  bone,  and  if  one  or  two  vertebra? 
alone  are  affected    there  will  result  a  sharp  angular  deformity  (kyphosis), 

the  convex  angle  being  directed 
backwards ;  where  several  bodies  are 
affected  the  curve  will  be  more  gradual ; 
lateral  deviation  does  occasionally  occur 
but  is  seldom  great,  never  reaching 
the  degree  found  in  static  disease  of  the 
spine.  In  order  to  maintain  the  erect 
position  and  compensate  for  the  acute 
localized  kyphosis,  the  vertebral  column 
above  and  below  this  point  assumes  a 
position  of  lordosis,  which  accentuates 
the  primary  curve  but  restores  the 
column  to  the  erect  position.  The 
calibre  of  the  spinal  canal  is  but  little 
affected  by  the  curvature,  however 
acute,  and  practically  always  remains 
sufficiently  patent  not  to  press  on  the 
spinal  cord.  Pressure  on  the  cord  is 
due  to  the  presence  of  pus,  granulation 
or  fibrous  tissue  forming  in  the  extra- 
dural space. 

Abscess-formation.  Just  as  in  tuber- 
culous disease  of  bone  elsewhere,  there 
is  a  tendency  if  the  disease  progresses 
for  cold  abscesses  to  form,  which  force 
their  way  along  muscle-sheaths  and 
fascial  planes,  pointing  at  a  consider- 
able distance  from  the  original  focus. 
Healing  of  the  disease  is  by  the  transformation  of  the  rarefied  bone  and 
granulation  tissue  into  fibrous  tissue,  which  becomes  ossified.  If  there 
has  been  much  destruction  of  bone  there  will  be  permanent  deformity  in 
the  shape  of  a  "  hump  "  or  "  hunch,"  old  abscesses  may  dry  up  and  become 
fibrosed  and  calcified.  During  the  process  of  healing  the  fibrous  tissue, 
formed  inside  the  spinal  canal,  may  press  on  the  cord,  causing  paraplegia. 

In  favourable  cases  the  lesion  may  heal  before  deformity  is  present, 
and  with  but  slight  alteration  in  mobility  of  the  spinal  column. 
Signs.     At  the  commencement  are  noted  : 
(1)  Pain  and  tenderness,  both  local  and  referred. 
(L'j  Localized  rigidity. 


FlG.    174.      Tuberculous   spinal   caries, 

Blight      lumbar     kyphosis     practically 

healed. 


SIGNS  OF  SPINAL  TUBERCULOSIS  439 

Later  there  will  be  (3)  deformity  ;  (4)  abscess-formation  ;  (5)  nervous 
signs. 

The  last  two  conditions  may  be  regarded  as  complications,  since  many 
cases  recover  without  their  being  noted. 

(1)  Pain  is  a  variable  symptom  and  maybe  slight.  Thus  one  patient 
developed  a  kyphotic  curvature  from  caries  while  doing  pick-and-shovel- 
work  ;  nor  did  he  develop  a  lumbar  abscess  till  ten  years  later.  More 
commonly  pain  is  marked  locally  and  the  patient  feels  as  if  the  back  were 
breaking.  Pressure  on  the  nerve-roots  may  be  referred  to  the  front  of  the 
body  along  the  distribution  of  the  nerves  ;  thus  in  children  with  dorsal  caries 
"  belly-ache  "  is  often  the  earliest  symptom,  and  referred  pain  in  the  arms 
or  legs  from  cervical  or  lumbar  disease  is  also  met  with.  Tenderness  may 
be  elicited  by  percussing  the  spines  of  the  vertebra?  all  the  way  down  till 
the  patient  complains  of  tenderness  at  one  spot,  but  as  such  tenderness  is 
also  present  in  neurasthenic  states  the  observation  by  itself  is  of  little  value. 
A  more  reliable  method  is  to  jar  the  top  of  the  skull,  not  too  forcibly,  and 
note  if  the  patient  feels  pain  or  uneasiness  in  some  part  of  the  spine.  Or 
the  patient  may  be  asked  to  jump  in  the  air  and  land  on  the  heels  with 
the  legs  extended  ;  if  caries  be  present  it  is  unlikely  that  he  can  be  persuaded 
to  do  this.  Local  tenderness  caused  by  jarring  the  spine  elsewhere  is 
tolerably  good  evidence  of  spinal  disease.  The  attitude  may  afford  good 
evidence  of  the  pain  and  tenderness  on  movement ;  thus  in  cervical  caries 
a  child  often  holds  the  head  with  both  hands  to  lessen  the  strain  on  the 
diseased  vertebrae,  or  if  the  disease  be  in  the  dorsal  region  walks  with  the 
weight  of  the  head  and  shoulders  supported  by  the  hands  placed  on  the 
knees,  and  does  not  flex  the  spine  when  picking  up  an  object  off  the  floor 
but  bends  the  knees  and  keeps  the  spine  straight  and  rigid. 

(2)  Localized  Rigidity.  In  the  early  stages  rigidity  is  from  muscular 
spasm  to  keep  the  diseased  parts  at  rest,  as  in  disease  of  other  joints.  Later 
there  will  be  in  addition  organic  fixation  from  development  of  fibrous  tissue 
or  new  bone,  i.e.  ankylosis.  In  the  early  stages  the  rigidity  extends  above 
and  below  the  part  affected.  Rigidity  is  tested  in  children  by  placing  the 
patient  on  the  face,  grasping  the  ankles,  and  lifting  the  extended  legs  off 
the  couch,  so  as  to  produce  lordosis  of  the  spine.  In  small  children  the 
legs  can  readily  be  raised  in  this  way  to  beyond  a  right-angle  with  the 
horizontal,  but  if  the  dorsal  or  lumbar  spine  be  affected  this  mobility  is 
greatly  diminished.  In  the  adult  examination  of  the  spine  is  made  in  the 
sitting  or  standing  position,  the  hands  being  placed  on  the  spines  of  the 
vertebrae  to  detect  local  loss  of  movement.  In  the  lumbar  region  such  loss 
of  mobility  is  readily  noted,  but  in  the  dorsal  region  in  adults  the  normal 
mobility  is  small  and  the  question  of  rigidity  here  is  less  easy  to  settle. 

In  the  cervical  region  rigidity  is  easily  found,  but  not  only  flexion  and 
extension  are  to  be  examined  ;  rotation  at  the  atlanto-axial  joint  must  be 
investigated,  for  this  is  often  affected. 

Deformity.  Pain,  rigidity,  and  tenderness  may  be  the  only  signs  for 
some  little  while,  but  usually  by  the  time  the  disease  is  sufficiently  marked 


no  A  TEXTBOOK  OF  SURGERY 

r<>  bring  the  patient  up  for  consultation,  deformity  is  presenl  as  well  -  indeed 
in  many  instances  the  tirst  thing  uoted  by  the  patient  or  the  parents  is  a 
"lump"  in  the  back.  The  deformity  is  due  to  the  crumpling  up  of  the 
rarefied  vertebral  bodies,  which  causes  angular  kyphosis.  Should  the 
disease  be  confined  to  the  Laminae  there  will  be  no  deformity  except  such 
as  may  be  due  to  formation  of  abscesses.  The  "  hunch  "  or  "  angular 
curvature  '*  hardly  requires  further  consideration  in  the  dorsal  and  lumbar 
regions,  except  to  note  that  it  is  almost  invariably  pure  kyphosis,  lateral 
curvature  being  uncommon  except  in  a  very  minor  degree.  In  the  neck  the 
*"  hunch  "  is  less  obvious  as  such,  but  the  curious  position  of  "  poked  head  " 
with  shortening  of  the  neck  so  that  the  head  seems  to  rise  from  between  the 
shoulders  is  very  characteristic.  The  compensatory  lordosis  above  and 
below  the  primary  angle  has  been  mentioned  already.  Secondary  changes 
are  also  found  in  the  thorax,  which  becomes  deeper  from  front  to  back, 
like  that  of  a  quadruped,  the  thoracic  viscera  being  crowded  together  and 
pushing  the  diaphragm  downwards,  causing  the  abdomen  to  protrude, 
giving  the  "  pot-bellied  "  effect  noted  in  cases  of  dorsal  or  lumbar  caries. 
The  changes  in  the  pelvis  causing  it  to  assume  the  "  funnel  shape  "  with 
considerable  diminution  of  its  outlet,  are  of  great  importance  in  obstetric 
medicine  owing  to  the  difficulty  thereby  caused  in  labour. 

(3)  An  X-ray  investigation  will  show  rarefaction  of  the  bone  or  the 
presence  of  abscesses,  and  may  help  to  differentiate  from  such  conditions 
as  aortic  aneurysm,  which  also  may  cause  pain  in  the  back. 

(i)  Abscess.  This,  although  not  developing  for  some  time  after  the 
disease  really  starts,  may  be  the  first  thing  noticed  by  the  patient ;  indeed 
the  primary  condition  may  elude  the  surgical  investigation,  and  the  prac- 
titioner should  always  be  on  his  guard  in  cases  of  cold  abscess  close  to  the 
spine  not  to  miss  a  case  of  spinal  caries.  In  most  instances  the  pus  forms 
under  the  anterior  common  ligament  in  front  of  the  bodies  and  passes  out 
towards  the  surface  along  different  paths.  It  may  keep  in  front  of  the 
spinal  axis  or  pass  backwards  into  the  dorsal  or  lumbar  regions.  When 
passing  forwards  two  types  of  abscess  are"  found,  the  (a)  retropharyngeal 
and  (b)  the  psoas. 

(a)  A  retropharyngeal  abscess  due  to  cervical  caries,  after  penetrating 
the  anterior  common  ligament,  lies  under  the  prevertebral  fascia  and  tracks 
down  along  the  prevertebral  muscles,  which  become  destroyed.  Such  an 
abscess  will  bulge  into  the  pharynx,  causing  nasal,  pharyngeal  or  laryngeal 
obstruction,  and  as  it  passes  lower  into  the  thorax  may  compress  the  ceso- 
phagus  and  trachea.  It  often  spreads  laterally,  usually  behind  the  carotid 
Bheath,  to  point  in  the  posterior  triangle  of  the.  neck  (rarely  it  may  reach 
the  anterior  triangle  and  very  occasionally  the  axilla).  The  danger  of 
such  an  abscess  is,  first,  from  obstruction  to  respiration  :  secondly,  that  it 
burst  into  the  pharynx  and  possibly  cause  suffocation,  aspiration- 
pneumonia,  or  later,  if  these  dangers  are  escaped,  the  cavity  will  become 
infected  with  pyogenic  organisms  via  the  sinus,  leading  from  the  pharynx, 
and  the  suppuration  rendered  more  severe  and  indefinitely  prolonged. 


ABSCESSES  IX  SPIXAL  TUBERCULOSIS 


441 


Diagnosis.  The  chronic  fluctuating  swelling  at  the  back  of  the  pharynx 
is  characteristic,  especially  if  felt  as  well  in  the  posterior  triangle,  but  retro- 
pharyngeal abscess  may  also  be  due  to  breaking  down  of  caseating  retro- 
pharyngeal glands  and  acute  retropharyngeal  abscess,  which  is  akin  to 
quinsey,  is  also  found  behind  the  pharynx.  The  greater  rapidity  of  onset, 
with  fever  and  more  urgent  respiratory  embarrassment  and  more  obvious 
signs  of  acute  inflammation,  will  distinguish  the  acute  form  :  from  chronic 
abscess  due  to  broken-down  tuberculous  glands  the  absence  of  signs  pointing 
to  spinal  disease  will  distinguish  (see  retropharyngeal 
abscess  in  Surgery  of  the  Xeck). 

(b)  Psoas  Abscess.  Chronic  pus  enters  the  psoas 
sheath  and  gravitates  down,  destroying  the  muscle. 
This  arises  either  directly  in  the  bodies  of  the  lumbar 
vertebrae,  from  which  the  muscle  takes  origin,  or 
tracks  down  from  the  lower  dorsal  vertebra?  under  the 
anterior  common  and  internal  arcuate  ligaments,  and 
so  reaches  the  sheath.  Disease  of  the  ilium  or  sacro- 
iliac synchondrosis  may  also  cause  a  very  similar  form  of 
abscess  (iliac  abscess).  Passing  down  in  the  muscle,  the 
psoas  abscess  leaves  the  abdomen  under  Poupart's 
ligament  to  the  outer  side  of  the  femoral  vessels  but, 
continuing  its  course,  passes  behind  them  and  soon  is 
on  their  inner  side  ;  here  the  bulging  formed  may 
resemble  a  femoral  hernia.  In  other  cases  it  may 
pass  back  along  the  internal  circumflex  vessels  to  the 
buttock  or  may  get  into  the  pelvis  and  so  to  the 
ischio-rectal  fossa.  The  usual  place  to  point  is  the 
inner  side  of  the  thigh  near  its  upper  end,  but  point- 
ing in  the  buttock,  ischio-rectal  fossa,  and  even  at  the 
heel  is  recorded. 

Abscesses  developing  in  the  course  of  spinal  disease, 
unless  specially  searched  for  by  the  surgeon,  are  seldom 
noted  by  the  patient  till  they  have  attained  a  consider- 
able size,  as  they  are  quite  painless.  The  fluctuating 
swelling  in  the  loin  associated  with  spinal  caries  suffices  for  diagnosis  in 
the  early  stages,  but  later,  fluctuation  of  the  swelling  above  and  below 
Poupart's  ligament  to  the  outer  or  sometimes  the  inner  side  of  the  femoral 
vessels  will  distinguish  this  condition  from  femoral  hernia  or  chronic  appendix 
abscess. 

In  obscure  swellings  of  the  loin  and  iliac  fossa  the  spine  should  be  criti- 
cally examined. 

(c)  Chronic  abscesses  seldom  pass  backward  in  the  neck,  but  in  the 
dorsal  and  lumbar  regions  it  is  common  for  pus  to  travel  via  the  posterior 
primary  divisions  of  the  nerves  and  the  vessels  which  accompany  them. 
Such  abscesses  are  called  dorsal  and  lumbar  respectively,  and  lie  about  two 
to  three  inches  from  the  mid-line.     In  some  instances  the  abscess  passes 


Fig. 


Caries 


the  spine  at  the  clorsi- 
lunibar  junction  giving 
rise  to  a  psoas  (gravi- 
tation) abscess. 


A  TEXTBOOK  OF  SURGERY 

along  the  rib  and  reaches  the  surface  via  the  lateral  cutaneous  branch  of 
an  intercostal  nerve. 

I )    .,/ .     In  the  dorsal  (thoracic)  region  they  arc  to  be  distinguished 

from  cold   al  secondary   to   tuberculous   ribs,   which,   apart   from 

operation,  may  not  be  easy  it'  the  spinal  disease  is  not  well  marked.      From 
pointing  empyema  the  impulse  on  coughing,  the  signs  of  compression  of 
the  rang  by  fluid,  will  discriminate,  but  empyemas  may  arise  from  such 
>ses. 

-  'phenomena  arising  in  spinal  disease  are  due.  in  the  earlier 
3,  to  compression  myelitis  from  formation  of  granulation  tissue  and 
pus  in  the  spinal  canal,  around  the  cord  ;  later  to  strangling  of  the  cord  by 
the  fibrous  tissue  resulting  from  this  when  healing.  In  the  early  stages 
the  legs  become  weak,  the  knee-jerks  are  increased,  ankle  clonus  may  be 
present,  and  the  upward  plantar  reflex  response  of  the  great  toe  (Babinski) 
is  present.  Later  there  is  marked  spastic  paralysis  with  loss  of  sphincter- 
control,  resulting  in  incontinence  of  faeces  and  reflex  micturition  or  retention 
of  urine  with  dribbling  overflow,  according  to  the  site  of  the  cord  lesiou. 
As  mentioned,  pressure  from  bony  deformity  hardly  ever  occurs,  but  it 
does  occasionally  take  place  in  the  upper  cervical  portion  of  the  spine, 
especially  at  the  atlanto-axial  joint,  where  a  slipping  of  the  occiput  and 
atlas  forward  has  furnished  a  dramatic  and  unexpected  ending  from  sudden 
compression  of  the  cord  above  the  origin  of  the  phrenic  nerve  and  death 
from  asphyxia  and  shock,  the  moral  being  that  the  head  must  be  kept 
steadied  with  the  greatest  care  in  cases  of  cervical  caries,  especially  when 
affecting  the  upper  two  vertebrae. 

Prognosis.  The  course  of  tuberculosis  of  the  spine  varies  enormously 
in  different  individuals.  In  some  the  lesion  heals  with  no  attention  or 
but  very  little,  while  in  others  the  course  is  progressively  do  wm  wards  in 
spite  of  every  care,  ending  in  death  from  infected  abscesses,  bedsores, 
paraplegia,  cystitis,  &c.  Most  cases,  however,  if  under  supervision  for 
some  years  do  well,  though  permanent  deformity  is  usual  and  complete 
resolution  rare.  The  ultimate  prognosis,  however,  cannot  be  considered 
good,  for  though  these  patients  survive  many  years  we  seldom  see  elderly 
hunchbacks,  and  yet  young  ones  are  common  enough.  The  alteration  in 
size  of  the  thoracic  and  abdominal  cavities  is  too  great  a  handicap  for  the 
vital  functions  to  be  properly  carried  out  over  the  normal  term  of  years. 
Relapses,  with  recurrence  of  caries  and  formation  of  residual  abscesses, 
are  not  uncommon. 

Diagnosis,  (a)  From  other  diseases  of  the  spinal  column.  Caries  of 
syphilitic  or  typhoid  origin  presents  similar  features,  but  the  history  and 
.-'•rum  reaction  will  help  in  diagnosis.  Tuberculosis  of  the  spine  is  the 
only  infective  form  to  be  expected  in  children.  Secondary  malignant 
disease  may  have  similar  features,  but  the  advance  of  disability  and  defor- 
mity is  more  rapid,  and  the  presence  of  a  focus  of  malignant  disease  else- 
when  \e  in  adults.     Hydatids  and  aneurysm  produce  similar 

pain  in  the  early  stage  from  erosion  of  the  bone.     In  the  latter  instance 


DIAGNOSIS  OF  SPINAL  CARIES  443 

examination  of  the  chest  and  abdomen,  the  pulses  and  radiography,  will 
be  of  assistance. 

Disease  producing  marked  deformity  of  the  spine  without  caries,  of 
which  scoliosis  is  the  great  example,  and  also  rickets  in  young  children,  is 
distinguished  by  the  curves  being  gradual  and  not  angular,  by  there  being 
usually  lateral  and  rotary  deformity  as  well,  and  by  the  absence  of  tenderness 
and  rigidity  till  later  in  the  case  when  nerve-pressure  is  present,  and,  as 
seen  in  radiographs,  by  the  absence  of  rarefaction  of  the  bones  in  spite  of 
great  deformity.  Functional  rigidity  and  pain  may  be  difficult  to  distin- 
guish from  Pott's  disease,  but  the  tendency  for  the  position  of  these  to 
alter,  that  deformity — if  present — is  exaggerated  or  of  unusual  type,  and 
the  absence  of  tenderness  on  jarring  the  skull  or  heels  and  absence  of  radio- 
graphic corroboration,  are  distinctive  points  ;  the  greatest  care,  however, 
must  be  taken  before  concluding  that  a  lesion  of  the  spine  is  functional. 

(b)  Such  conditions  as  lumbago  or  muscular  rhemnatism  are  to  be 
distinguished  by  the  absence  of  pain  on  jarring,  and  its  occurrence  in  robust 
middle-aged  men  and  history  of  previous  attacks  relieved  by  massage  and 
salicylates,  &c. 

Mistaking  the  special  cases  where  the  pain  is  referred  to  the  abdomen,  for 
disease   of  this   cavity  is  avoided 
by  examining  the  spine  in  children 
with  obscure  abdominal  symptoms. 

The  diagnosis  of  cold  abscesses 
of  spinal  origin  has  been  already      FlG   176     Double  hip-splint  with  head  rest 
discussed.    We  may  add,  however,  and  supports  for  the  feet, 

that  psoas  myositis  is  caused  by 

other  conditions  than  cold  abscess  ;  thus  inflammation  of  the  appendix  may 
spread  to  the  muscle,  as  may  affections  of  the  deep  iliac  glands,  and  cause  a 
similar  flexion  of  the  hip.  Abscesses  originating  in  disease  of  the  sacro-iliac 
joint  will  spread  along  the  iliacus  to  below  Poupart's  ligament  but  will  not  be 
felt  in  the  psoas-sheath  high  in  the  loin.  Abscess  secondary  to  hip  disease 
very  rarely  rises  above  Poupart's  ligament.  Perinephric  abscess  ma}-  be 
a  form  of  lumbar  abscess  and  due  to  spinal  caries,  though  more  usually 
secondary  to  appendicitis  or  renal  disease.  A  careful  inquiry  into  the 
history  and  full  examination  will  generally  decide  in  such  cases. 

Treatment.  The  usual  treatment  for  tuberculosis — viz.  open-air,  sun- 
light, and  good  feeding — must  be  carried  out  for  one  or  more  years  and 
the  spine  kept  at  rest.  This  is  best  accomplished  by  placing  the  patient  in 
the  recumbent  position  assisted  by  some  apparatus  to  limit  spinal  movement, 
such  as  a  splint  or  plaster-case.  The  recumbent  position  should  be  main- 
tained for  about  six  months  after  pain  or  other  signs  of  active  disease  have 
ceased,  and  then  the  patient  gradually  raised  to  the  erect  position,  the 
spine  being  supported  by  some  apparatus.  Children  while  in  the  recumbent 
position  may  be  kept  on  a  double  Thomas's  hip-splint  with  a  head-piece 
if  the  disease  is  above  the  lower  dorsal  region.  Quite  as  good  and  cheaper 
is  Bradford's  frame,  which  consists  of  an  oblong  frame  of  gas-piping  rather 


Ill 


A  TEXTBOOK  OF  SURGERY 


larger  than  the  patient,  on  which  is  Btretched  canvas  to  support  the  patient. 
The  frame  may  be  bent  into  a  positioD  of  hyper-extension  (lordosis)  to  help 
correct  the  kyphotic  deformity.     Phelps'  box  is  cumbersome  and  no  better 

than  the  above  apparatus.  Adults  arc  too  bulky  to  be  nursed  on  the 
Thomas's  splint  or  Bradford  frame,  and  the  spine  must  be  controlled  by  a 

rigid  jacket   with  head-support 
it'  necessary. 

Spinal  jackets  are  used  to 
control  the  spine  in  adults 
while  recumbent,  and  in  both 
children  and  adults  when  the 
patient  is  allowed  to  sit  and 
stand  up.  These  are  made 
either  of  leather  or  poroplastic 
or  celluloid  (fashioned  on  a 
east  taken  of  the  patient),  or  of 
plaster  of  Paris  applied  directly 
to  the  patient.  Where  poro- 
plastic or  leather  is  used  steel 
supports  should  always  be 
added,  or  the  jacket  will 
crumple  up  in  a  short  time 
from  the  weight  of  the  patient. 
The  plaster  -  of  -  Paris  jacket 
(Sayre)  is  applied  with  the 
patient  in  the  erect  position, 
the  head  and  axillae  being  sup- 
ported by  slings  from  a  tall 
tripod,  which  cause  some  ex- 
tension of  the  spine  and  take 
some  of  the  patient's  wreight. 
A  thin  vest  is  put  on  the 
stripped  patient,  the  bony 
prominences  of  the  iliac  crests 
and  sacrum  well  padded  with  wool  bandaged  on,  and  the  plaster  applied 
from  the  trochanters  of  the  femur  to  the  nipples.  The  plaster  must  be 
strong,  and  if  the  disease  extends  above  the  lower  dorsal  vertebrae  a  steel 
rod  is  incorporated  in  the  back  of  the  plaster  and  extends  up  over  the  head 
as  a  "  jury  mast "  to  which  the  head  is  slung  by  the  chin  and  occiput,  thus 
taking  the  weight  of  the  upper  trunk  and  head  off  the  spine.  In  small 
children  and  infants  an  effective  method  of  using  plaster  is  to  place  the 
child  on  the  belly  and  after  covering  the  bony  prominences  with  wool,  to 
a  "carapace"  of  plaster  and  Bavarian  flannel  extending  from  the 
top  of  the  head  to  the  fold  of  the  buttocks.  This  when  dry  forms  a  shell  in 
which  the  child  can  lie  and  into  which  it  is  bandaged  ;  of  course,  this  plan 
is  only  suitable  while  tin'  patient  is  in  the  recumbent  position. 


Fig. 


177.     A  light  strong  jacket  support  suitable 
for  healing  spinal  caries. 


TREATMENT  OF  SPINAL  CARIES  445 

Forcible  correction  of  the  kyphotic  curve  is  to  be  avoided,  but  by  altering 
the  shape  of  the  Thomas's  splint  or  Bradford's  frame  from  time  to  time  the 
angular  curve  can  be  gradually  lessened. 

While  the  patient  is  confined  to  a  splint  or  plaster  examination  should 
be  made  at  regular  intervals,  not  only  as  regards  the  general  state  but  to 
see  that  there  is  no  formation  of  abscess  in  the  psoas,  retropharyngeal,  or 
lumbar  positions,  while  the  legs  should  be  tested  and  watch  kept  over 
the  sphincters  for  signs  of  pressure  on  the  cord.  The  nutrition  of  the  limbs 
should  be  maintained  by  massage  while  in  the  recumbent  position. 

The  jacket  or  other  ambulatory  apparatus  should  be  retained  for  at 
least  a  year  after  all  signs  of  active  disease— such  as  pain,  tenderness, 
abscess — have  disappeared  and  only  gradually  discarded,  the  head-piece 
removed  first  and  the  jacket  gradually  cut  down. 

Treatment  op  Spinal  Abscesses.  In  these  cases  it  is  all-important  to 
treat  the  underlying  condition  of  spinal  caries.  It  is  no  use  aspirating  or 
opening  a  psoas-abscess  and  neglecting  the  caries  of  the  dorsi-lumbar 
region,  in  which  it  originates  :  one  might  as  well  remove  enlarged  glands 
of  the  neck  and  leave  a  cancer  of  the  tongue. 

When  a  spinal  abscess  is  discovered  in  the  course  of  a  case  of  spinal 
caries  which  is  not  in  the  recumbent  position,  the  patient  should  be  placed 
on  the  back  and  suitable  retentive  apparatus  applied.  Under  good  general 
conditions  many  abscesses  will  become  smaller  and  ultimately  dry  up,  but 
if  advancing  in  spite  of  such  treatment  more  radical  measures  should  be 
employed. 

Simple  aspiration  is  of  little  use  ;  injection  of  some  substance  to  soften 
the  contents  must  be  employed  and  has  proved  successful  for  lumbar  and 
psoas  abscess  {sze  p.  409).  A  retro-pharyngeal  abscess  can  hardly  be 
aspirated  with  safety  on  account  of  the  proximity  of  the  large  vessels,  so 
it  should  be  opened  as  soon  as  there  is  any  respiratory  difficulty  or  when 
spreading  to  the  skin  by  an  incision  behind  the  sternomastoid  muscle, 
pushing  the  vessels  in  the  carotid  sheath  forwards.  After  swabbing  out, 
the  abscess  is  closed  again. 

A  psoas  abscess  is  best  opened  or  aspirated  above  Poupart's  ligament 
so  that  the  opening  is  as  little  dependent  as  possible,  which  diminishes  the 
risk  of  infecting  the  track  through  which  pus  is  evacuated.  There  seems 
little  advantage  in  opening  these  abscesses  in  the  loin  with  a  view  of  removing 
carious  portions  of  the  vertebras. 

Treatment  of  Paraplegia.  This  can  usually  be  relieved  by  strict 
enforcement  of  the  recumbent  position,  with  perhaps  extension  as  well. 
Care  should  be  taken  to  prevent  formation  of  bed-sores  and  cystitis,  if 
catheterization  is  needed.  It  is  very  important  to  recognize  the  early 
signs  of  paraplegia,  viz.  weakness  of  the  legs  and  increased  reflexes,  so  as 
to  commence  recumbent  treatment  as  soon  as  possible.  Operative  treat- 
ment is  indicated  when  the  condition  is  getting  rapidly  worse  (cystitis,  bed- 
sores) or  not  improving  after  three  months  of  complete  recumbency.  The 
operation  consists  in  "  laminectomy  "  over  the  kyphotic  curve  and  removing 


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A  TEXTBOOK  OF  SURGERY 


the  pus  and  granulation  tissue  from  the  extradural  cavity.  By  gently 
displacing  the  cord  the  carious  bodies  of  the  vertebrae  can  be  curetted. 
The  results  are  fair  temporarily,  but  later  fibrosis  of  the  granulations  is  likely 


Fig.  178.     Operative  ankj'losis  of  the  spine  for  caries  (Albce's  operation). 

(Mr.  Milne's  case.) 

to  lead  to  return  of  the  paraplegia,  and  then  operative  measures  are  almost 
hopeless. 

Operative  Treatment  of  Spinal  Tuberculosis  (Artificial  Anky- 
losis). Apart  from  the  treatment  of  paraplegia,  operative  treatment  has  been 
advocated  in  ordinary  eases  on  the  following  grounds.  Since  the  natural 
cure  is  by  ankylosis  of  the  bones  affected,  this  might  be  achieved  more 
ditiously  by  performing  some  operation  to  secure  rapid  ankylosis. 
ttacking  the  bodies  in  such  an  operation  is  out  of  the  question,  ankylosis 
has  been  produced  in  the  spines,  thus  forming  a  firm  splint  of  bone  which 
prevents  any  movement  of  the  part  thus  treated.     Two  methods  have  been 


SPONDYLITIS  447 

employed.  The  first  (Hibbs)  is  to  expose  the  spines  over  the  angular  curve, 
bare  them  of  periosteum  above  and  below,  and  then  fracture  them  through 
their  bases  and  bend  them  down  over  each  other.  In  this  way  the  spines 
for  some  distance  become  ankylosed.  The  other  method  (Albee)  is  to 
split  the  spines  in  the  affected  area  and  insert  a  bone-graft  (taken  from  the 
front  of  the  tibia)  in  the  gap.  The  graft,  when  it  has  taken  root,  will  effec- 
tively bind  all  the  spines  in  the  affected  region  together.  The  patients 
are  recumbent  in  bed  eight  weeks  after  operation,  sit  up  for  a  month,  then 
walk  with  a  brace  for  another  month,  and  then  are  allowed  to  go  without 
support  (Hibbs).  Good  results  are  reported,  and  the  fact  that  the  patient 
can  get  about  without  external  supports  such  as  jackets  would  appear  to 
be  a  great  advantage.  But  more  evidence  is  needed  before  this  method 
can  be  looked  upon  as  a  routine  treatment. 

(2)  Syphilis  of  the  Spine.  This  condition  resembles  tuberculosis  in 
general  pathology  and  signs,  but  is  less  common  and  usually  found  in  adults. 
The  affection  consists  of  a  gummatous  osteitis  with  caries  and  necrosis, 
leading  to  deformity,  as  in  the  tuberculous  form.  The  cervical  spine  is 
most  often  affected  and  retropharyngeal  abscess  may  result.  The  diagnosis 
is  made  on  other  signs  of  syphilis  and  on  the  serum  reaction,  but  the 
possibility  of  tuberculosis  occurring  in  a  syphilitic  patient  should  not  be 
forgotten. 

Treatment  is  as  for  tuberculosis  with  the  addition  of  antisyphilitic 
measures. 

(3)  Typhoid  Spine.  This  condition  presents  similar  physical  signs  to 
those  of  tuberculous  disease,  but  is  found  after  enteric  fever  and  in  adults 
affecting  the  dorsal  region.     The  treatment  is  as  for  tuberculous  spine. 

(c)  Rheumatoid  Affections  of  the  Spine  :  Spondylitis.  There  is 
a  good  deal  of  uncertainty  as  to  the  entity  of  the  various  types  described  : 
some  seem  to  be  of  definite  causation,  e.g.  from  injury,  hereditary  changes, 
or  gonorrhoea — while  in  others  no  cause  is  definitely  known.  The  changes 
are  found  in  bones,  joints,  and  ligaments  as  in  osteoarthritis  elsewhere,  with 
development  of  osteophytes,  sclerosis  and  rarefaction  of  bone,  ossification 
of  ligaments,  and  ankylosis  of  joints. 

The  disease,  which  occurs  in  middle  life,  may  be  (1)  general,  (2)  local. 

(1)  When  general  there  maybe,  (a)  a  progressive  general  kyphosis  (the 
rhizomelic  spondylosis  of  Marie  and  Striimpel)  occurring  in  males,  very 
chronic  and  persistent  in  course,  till  the  whole  trunk  is  bowed  forward  and 
the  patient  is  obliged  to  face  the  ground,  the  arms  hanging  in  a  plane  much 
anterior  to  that  of  the  legs.  Sometimes  the  onset  is  acute,  complete  defor- 
mity and  ankylosis  resulting  in  a  few  months.  There  is  often  much  pain 
from  pressure  on  nerve-roots  and  muscular  atrophy. 

(b)  In  another  form  there  is  ankylosis  from  profusion  of  osteophytic 
outgrowths  without  kyphosis  (osteophytic  vertebral  rheumatism,  or  poker- 
back),  all  the  normal  curves  being  diminished  and  the  spinal  column  approxi 
mating  to  a  straight  line.     Pain  from  pressure  on  the  nerve-roots  is  common 
in  this  type  also.     The  joints  of  the  limbs  may  or'may  not  be  affected,  and 


M>  A  TKXTBOOK  OF  SURGERY 

this  allows  of  further  types  being  described,  but  there  is  little  reason  for 
such  refinements. 

(2)  When  the  condition  is  localized  it  follows  injury  to  the  dorsal  region 
and  there  is  usually  a  history  of  other  members  of  the  family  being  affected 
in  a  similar  manner  (von  Bechtorew).  A  dorsal  kyphosis  develops,  with 
pain,  anaesthesia,  and  muscular  wasting  from  pressure  on  nerve-roots.  It 
is  uncertain  to  what  degree  this  condition  is  a  traumatic  osteo-arthritis  or  a 
sprain-fracture  of  the  spinal  column  (Kiimmel)  associated  with  temporary 
paraplegia  :  later,  weakness  of  the  lower  limbs  and  development  of  a 
-  hump." 

Diagnosis.  The  diffuse  type  is  distinguished  from  osteitis  deformans 
by  the  absence  of  changes  in  the  long  bones  and  cranium.  The  local  form 
closely  resembles  Pott's  disease  ;  nor  does  it  appear  that  quiet  tuberculous 
caries  initiated  by  injury  has  been  completely  excluded  in  cases  described 
under  this  title. 

Treatment.  In  the  milder  cases  massage,  hydrotherapy,  hot-air  baths, 
and  tonic  drugs  may  cause  temporary  relief,  but  where  deformity  is  in- 
creasing it  seems  more  reasonable  to  prevent  its  increase  by  the  use  of 
supporting- jackets  or  recumbency  with  extension,  since  if  ankylosis  must 
occur  the  condition  is  less  pitiable  with  the  spine  in  the  erect  position  than 
with  grave  kyphosis  so  that  the  patient  can  only  look  on  the  ground. 

(II)  Static  Deformities  of  the  Spine.  Apart  from  the  deformities 
due  to  inflammation  or  tumour-formation,  the  spine  may  deviate  from 
its  normal  lines  owing  to  a  relative  weakness  of  the  parts  concerned  in  its 
structure,  which  are  unable  to  resist  the  weight  of  the  body.  This  implies 
a  loss  of  tone  in  the  muscles,  a  laxity  of  ligaments,  and  a  softening  of  the 
bones,  met  with  chiefly  in  rickets  and  adolescence  but  also  in  osteomalacia, 
debility,  anaemia,  &c. 

The  deformity  may  take  the  form  of  forward,  backward,  or  lateral 
bending  of  the  spine,  but  is  most  commonly  a  combination  of  all  three  with 
rotary  deformity  as  well,  and  is  then  known  as  scoliosis. 

In  addition  to  weakness  of  the  spine,  or  even  where  there  is  no  obvious 
defect  of  this  nature,  other  factors  are  needed  to  bring  about  deformity. 
These  fall  into  two  classes  : 

(a)  In  the  first  group  are  included  improper  habits  of  standing,  sitting, 
&c,  and  the  resulting  deformity  may  be  regarded  as  primary  scoliosis, 
kyphosis,  lordosis,  &c. 

(b)  In  the  second  group  are  placed  organic  defects  of  the  spine  or  other 
parts  of  the  body,  and  the  deformity  is  then  secondary. 

(1)  Primary  deformities  of  the  spine  are  due  to  many  causes.  Constant 
stooping  over  work,  whether  from  myopia,  prolonged  reading  in  a  bad 
light,  or  the  nature  of  the  occupation,  as  in  following  the  plough,  account 
for  the  kyphosis  of  round-shouldered  children,  the  scholar's  stoop,  the 
ploughman's  slouch.  &c.  Carrying  a  weight  on  one  arm,  as  a  nursemaid 
does  a  baby,  riding  side-saddle,  working  with  the  body-weight  on  one  leg 
as  at  the  turning-lathe  or  printing-press,  produce  a  flexion  of  the  body  to 


LORDOSIS  AND  KYPHOSIS  449 

the  side  opposite  to  which  the  weight  tends  to  pull  the  spine,  and  finally 
permanent  deformity  results. 

Merely  assuming  a  faulty  position  repeatedly,  as  in  writing,  will  produce 
the  same  results  ;  unilateral  games  have  the  same  tendency  but  to  a  less 
degree,  since  all  movements  exercise  the  spinal  muscles  and  help  to  reduce 
deformity,  but  slight  defects  from  this  cause  are  common  in  strong,  athletic 
persons.  Scoliosis  is  especially  frequent  in  middle-class  girls  who  have  to 
sit  at  home  and  do  needlework  or  other  polite  accomplishments  without 
much  outdoor -exercise,  while  in  the  rougher  "  factory  type  "  the  condition 
is  much  less  common. 

(2)  Secondary  spinal  deformity  may  be  purely  compensatory,  as  in  the 
lordosis  which  compensates  angular  kyphosis,  already  described  in  Pott's 
disease.  Again,  in  the  condition  known  as  spondylolisthesis,  where  the  last 
lumbar  vertebra  slips  forward  over  the  sacrum,  producing  acute  kyphosis 
at  this  point,  there  is  a  marked  compensatory  lordosis.  Similarly,  in 
double  congenital  dislocation  of  the  hips  the  pelvis  is  rotated  downward  to 
allow  of  standing,  and  the  spine  is  in  a  position  of  lordosis  to  permit  of  the 
erect  position  being  assumed.  The  lordosis,  caused  by  abdominal  tumours, 
in  particular  pregnancy,  which  carries  the  centre  of  the  body  back  again 
till  it  is  between  the  feet,  is  of  similar  nature,  though  the  last  example  may 
be  regarded  as  physiological. 

Where  the  original  defect  is  unilateral  or  asymmetrical  the  deformity 
will  be  lateral  deviation  or  scoliosis.  Thus  there  may  be  failure  of  ossifica- 
tion of  half  a  vertebra,  causing  lateral  flexion  of  the  spine. 

Another  common  cause  is  torticollis,  where  scoliosis  compensates  for 
the  distorted  position  of  the  head. 

Contraction  of  the  chest- wall  from  empyema  or  fibroid  lung,  occasionally 
after  anterior  poliomyelitis  of  the  spinal  muscles,  may  result  in  lateral 
deviation.  Any  real  or  apparent  shortening  of  the  lower  limb  from  hip- 
disease,  congenital  dislocation,  coxa  vara,  badly  united  fracture,  knock- 
knee,  &c,  may  lead  to  secondary  deformity  of  the  spine.  A  perinephric 
abscess  gives  rise  to  acutely  developing  lateral  curvature.  Finally,  spinal 
deformity  may  be  due  to  nervous  disease,  as  that  found  in  Friedreich's 
hereditary  ataxia. 

Types  of  Deformity.  Mention  has  been  made  already  of  lordosis,  kyphosis, 
and  scoliosis,  according  as  the  curve  is  forward,  backward,  or  lateral. 

Lordosis  is  nearly  always  compensatory  and  therefore  secondary,  but 
it  may  arise  primarily  in  those  whose  backs  are  flexible  and  weak  and  who 
have  to  stand  a  long  time,  this  being  the  easiest  mode  of  sustaining  the 
erect  position. 

Kyphosis,  apart  from  Pott's  disease  and  the  rheumatoid  conditions,  is 
nearly  always  associated  with  scoliosis,  but  may  occur  in  a  pure  condition 
in  myopes,  students,  porters,  ploughmen,  old  age,  or  rickets.  The  deformity 
when  occurring  alone  is  of  seldom  more  than  cosmetic  importance,  and  if 
severe  or  in  young  subjects  requires  the  same  treatment  as  scoliosis,  with 
which  it  is  often  combined, 
i  29 


450 


A  TEXTBOOK  OF  SURGERY 


Scoliosis  or  Lateral  Curvature.  The  first  term  is  the  better,  since  in 
addition  to  the  lateral  curvature  there  is  always  some  rotation  of  the  bodies 
of  the  vertebrae  and  a  varying  degree  of  kyphosis  and  lordosis.  The  reason 
for  the  rotation  of  the  vertebrae  is  quite  simple.  Pure  lateral  flexion  is 
only  possible  to  a  limited  degree  on  account  of  the  interlocking  of  the 

articular  processes.  For  extensive  lateral 
flexion  to  take  place  rotation  is  essential, 
and  in  rotation  the  more  solid  but  movable 
bodies  deviate  from  the  central  line  of  the 
body  more  than  the  interlocking,  though 
less  massive,  articular  portions.  Owing  to 
the  rotation  the  movement,  which  would 
otherwise  be  pure  lateral  flexion,  becomes 
in  part  a  bending  forward  or  backward — 
i.e.  kyphosis  at  one  part,  lordosis  at 
another.  This. is  very  evident  if  speci- 
mens of  the  bones  from  advanced  cases 
of  scoliosis  are  examined,  and  in  this  way 
is  accounted  for  the  fact  that  the  spines 
are  much  less  deflected  from  the  mid-line 
than  are  the  bodies.  In  other  words, 
the  general  curvature  is  greater  than 
the  position  of  the  spines  would  lead 
one  to  suppose.  The  rotation  of  the 
bodies  in  the  dorsal  region  naturally 
carries  the  ribs  with  them,  and  this 
causes  the  angle  of  the  ribs  to  project 
back  on  the  side  to  which  the  con- 
vexity of  the  curve  and  the  bodies  of 
the  vertebrae  are  directed.  This  projec- 
tion behind  is  sometimes  called  the 
"  gibbus "  or  "  hump,"  and  there  is 
a  corresponding  projection  in  front  of 
the  opposite  side,  so  that  the  thorax, 
from  being  relatively  oblong  in  section, 
becomes  rhomboidal,  and  this  deformity 
diminishes  its  cavity  not  a  little.  (Fig.  181 . ) 
The  ribs  are  spread  out  widely  on  the  side 
of  the  convexity  and  crowded  together  on  the  concave  side.  The  pelvis 
also  becomes  narrowed  obliquely,  and  may  cause  difficulty  in  labour. 
In  the  early  stages  the  curvature  is  functional  only  and  can  be  com- 
pletely corrected  by  suitable  posture ;  later  the  intervertebral  discs 
become  compressed  and  the  bodies  altered  (wedge-shaped)  :  this  is  not 
to  be  confused  with  the  congenital  absence  of  half  vertebrae,  which  is 
also  a  cause  of  scoliosis.  The  jamming  together  of  the  articular  pro- 
cesses  leads    to    ankylosis ;     the  anterior   ligament  slips  round    to   the 


Fig.  179. 


Scoliosis,  moderate, 
girl  set.  6. 


SCOLIOSIS 


451 


concave,   shorter   side    of   the    curve,    the   ligaments    shorten   and   later 
calcify,  and  the  deformity  becomes  completely  fixed. 


Fig.  180.     Scoliosis  ;   large  left  gibbus  made  more  evident  by  flexing  the  spine. 

(Girl  set.  6.) 

Signs.     When  occurring  in  adolescents  the  condition  is  at  least  ten 
times  as  common  in  girls  as  in  boys,  and  attention  is  generally  called  to 


Fig    181.     Scoliosis.     A,  Section  of  the  normal  thorax.     B,  Section  of  scoliotic 
thorax  showing  the  deviation  and  rotation  of  the  vertebrae  and  the  resulting  dis- 
placement of  the  ribs  giving  the  thorax  a  rhomboidal  shape  in  section. 

scoliosis  by  what  is  called  "  growing  out  "  of  the  shoulder  or  hip  or  both  : 
the  former  is  due  to  the  scapula  being  carried  back  by  the  gibbus  or  hump 
of  the  ribs  on  the  convex  side,  the  latter  by  the  deviation  of  the  lumbar 


152 


A  TEXTBOOK  OF  SURGERY 


Bpine  fn.in  the  perpendicular,  carrying  with  it  the  abdominal  parietes  and 
leaving  the  hip  projecting.    (Fig.  L82.)     In  the  early  stages  there  is  often  ;i 

single  curve  to  one  side,  usually  the  right  ;  this  single  curve  later  is  broken  lip 
by  compensating  efforts  of  the  trunk  muscles,  into  dorsal  and  lumbar  curves 
—the  former  being  more  often  convex  to  the  right,  the  latter  to  the  left.     In 

such  a  case  the  gibbus  and  projection 
of  the  shoulder  will  be  to  the  right, 
while  the  projection  of  the  hip  is  to 
the  left.  The  occurrence  of  lordosis 
and  kyphosis  as  part  of  the  curvature 
has  been  mentioned  :  in  some  instances 
the  dorsal  kyphosis  is  very  marked, 
while  in  others  the  back  is  very  fairly 
flat.  In  early  cases  the  deformity 
disappears  on  extending  the  spine  and 
raising  the  arm  on  the  opposite  side 
to  the  gibbus,  thus  expanding  the  chest 
on  that  side  (key-note  position)  ;  the 
same  effect  may  be  produced  by  hang- 
ing on  an  obliquely  slung  trapeze.  On 
flexing  the  spine  the  deformity  becomes 
more  marked,  the  prominence  of  the 
ribs  standing  out  more  conspicuously 
(Fig.  183).  As  the  condition  advances 
the  deformity  becomes  irreducible  by 
posture  and  at  last  is  gross,  resembling 
at  first  sight  a  severe  case  of  Pott's 
disease  ;  closer  inspection  will  reveal  the 
rotation  of  the  vertebrae. 

Diagnosis.  In  early  eases,  there 
being  but  little  deviation  of  the  verte- 
brae, and  since  the  spines  of  these  move 
much  less  than  the  bodies,  we  note 
rather  the  contour  of  the  patient's 
body  than  the  spine.  On  making  the 
patient  stand  up  with  the  spine,  as  she 
thinks  straight,  and  the  arms  to  the  side,  the  natural  angle  between  the 
dependent  arm  and  the  body- wall  will  be  diminished  on  the  side  of  the  gibbus 
of  the  ribs  but  increased  on  the  other  side.  At  the  same  time  the  projec- 
tion and  raising  of  the  shoulder  may  be  noted  on  the  side  of  curvature  and 
the  projection  of  the  hip  on  the  other  side.  The  position  of  the  spine  can 
be  tested  by  dropping  a  plumb-line  from  the  occiput  and  marking  it  on 
the  back  with  pencil  ;  thus  slight  curves  are  detected.  The  shape  of  the 
thorax  may  be  investigated  with  the  cyrtometer  (a  jointed  lead  tape  which 
is  moulded  to  the  chest-wall  and  on  removal  by  unfolding  at  the  central 
joint  will  reproduce  a  horizontal  section  through  the  thorax). 


Pro.  182.     Scoliosis;   showing  opposing 

protrusion  of  left  iliac  crest. 


TREATMENT  OF  SCOLIOSIS 


453 


In  very  early  cases,  which  are  best  described  as  "  weak  spine,"  the 
deformity  will  be  found  to  vary  from  one  side  to  the  other  at  different 
examinations,  which  implies  that  there  is  a  readiness  for  scoliosis  to  develop 
(from  weak  muscles  and  lax  ligaments)  rather  than  a  proper  deformity 
actually  present.  It  is  important  to  recognize  such  early  cases,  as  the  best 
results  of  treatment  depend  on  commencing  before  the  deformity  is  advanced 
and  becoming  fixed. 

From  Pott's  disease  the  fact  that  the  deformity  is  a  large  open  curve 
or  two  or  more  alternating  curves,  and  that  there  is  lateral  flexion  and 
rotation,  no  abscess-formation 
at  any  stage,  and  no  rigidity 
till  the  case  is  considerably 
advanced,  while  nerve  symp- 
toms are  never  seen  till  very 
late  in  the  case  will  distinguish. 

Treatment.  (1)  Immediate 
causes  should  be  removed  or 
remedied  ;  e.g.  unequal  length 
of  legs  by  a  high-boot  or 
osteotomy,  replacement  of  dis- 
located hip,  &c. 

Torticollis  should  be  treated. 
Contraction  of  the  chest-wall 
from  empyema,  &c,  may  be 
much  improved  by  breathing 
exercises. 

(2)  Conditions  leading  to 
development  of  faulty  habits 
of  position,  such  as  myopia, 
adenoids,  should  be  treated. 

(3)  Faulty  positions  at  work  or  play  should  be  carefully  obviated.  The 
desk  and  seats  for  school-children  should  be  made  so  that  they  cannot 
readily  assume  a  sprawling,  faulty  position  with  lateral  curvature.  The 
times  for  sedentary  work  should  be  broken  up  by  frequent  intervals  for 
stretching  the  trunk  and  limbs  by  means  of  simple  exercises  of  the  Swedish 
type  for  a  few  minutes  (such  intervals  are  good  not  only  for  the  spine  but 
for  the  brain  as  well).  Care  should  be  taken  in  girls  with  weak  spines  of 
plaving  games  or  taking  exercises  where  one  side  of  the  body  is  most  used, 
as  riding  side-saddle  or  playing  hockey,  and  other  games  likely  to  cause 
stooping. 

Unilateral  games  where  the  body  is  in  the  erect  position  and  the  trunk 
often  hvperextended,  such  as  lawn-tennis,  are  much  less  likely  to  cause 
trouble  to  the  spine.  Attempts  should  be  made  to  keep  both  sides  of  the 
body  developed,  as  by  fencing  'ambidextrously,  swimming  breast-stroke, 
sculling  rather  than  rowing.  But,  however  asymmetrical  an  exercise  may 
be,  it  will  certainly  be  less  detrimental  than  standing,  sitting,  or  sprawling 


Fig.  183.     Scoliosis,  showing  the  increased  promin- 
ence of  tin-  ribs  seen  when  bending  forward. 


i:.l 


A  TEXTBOOK  OF  SURGERY 


in  bad  position.     Over-exercise  in  young  persons  from  carrying  weights  on 
one  arm  01  working  a  machine  with  one  leg  are  to  be  avoided. 

The  above  points  are  of  importance  in  the  prevention  of  scoliosis  but 
are  worth  considering  when  the  condition  is  to  be  treated. 

(4)  General  treatment  consists  in  maintaining  the  body-tone  by  open- 
air  life,  cold  baths,  massage,  exercise,  good  feeding,  early  bed  and  plenty  of 

it,  as  well  as  rest  on  the  flat  of  the 
back  for  half  an  hour  after  meals. 

(5)  Special  Treatment  in  the  Ado- 
lescent Form  of  Scoliosis.  The  general 
tone  must  be  improved  as  above  and 
suitable  combination  of  rest  on  the 
back  and  exercises  employed.  Of 
such  exercises  flexing  and  extending 
the  trunk  forward,  backward  and 
sideways,  as  well  as  circumducting 
and  twisting  movements,  should  be 
employed,  as  well  as  swimming 
breast-stroke  and  sculling.  Pro- 
longed standing  or  sitting  is  to  be 
avoided,  and  when  not  exercising 
the  supine  position  on  the  back  will 
give  the  spine  its  best  chance  of 
growing  straight.  A  useful  form 
of  exercises,  especially  for  smaller 
children,  are  those  of  Klapp.  The 
patients  crawl  on  all-fours,  this 
exercise  causing  alternating  flexion 
of  the  two  sides  of  the  trunk  with- 
out any  strain  on  the  ligaments  or 
bones  of  the  spine,  which  must 
occur  to  some  degree  in  all  standing 
exercises.  The  method  of  crawling 
is  as  follows  :  The  right  arm  is  ex- 
tended over  to  the  left  front  and 
the  head  flexed  in  this  direction, 
and  the  left  thigh  is  flexed  forcibly 
on  the  trunk  ;  these  movements  to- 
gether cause  acute  flexion  of  the  trunk  to  the  left.  As  progress  forward 
is  made  the  left  leg  is  extended,  the  right  thigh  flexed  at  the  hip,  and  the 
left  arm  extended  over  to  the  right  front,  causing  acute  flexion  of  the  trunk 
to  the  right.  (Fig.  185. )  In  this  manner  the  trunk-muscles  are  well  exercised 
and  flexibility  is  gained.  This  line  of  treatment  will  suffice  where  there  is  no 
permanent  deformity  or  where  this  is  slight  on  assuming  the  "  key-note  "  or 
"  best  "  position.  Where  the  deformity  is  marked  but  partly  reducible, 
special  exercises  should  be  used  to  reduce  the  deformity,  such  as  flexion 


Fig.  184.  Marked  scoliosis  ;  the  right  shoulder 
dropped,  the  right  side  of  the  thorax  promin- 
ent behind  (gibbus),  large  space  between  the 
arm  and  chest  on  left  side. 


TREATMENT  OF  SCOLIOSIS 


455 


and  rotation  of  the  trunk  towards  the  gibbus  or  crawling  round  the  latter 
as  a  fixed  point.  Deep  breathing  exercises  are  of  great  importance 
to  restore  the  normal  shape  capacity  to  the  thorax.  In  all  cases  the 
patient  should  be  placed  before  a  looking-glass  and  instructed  in  assuming 
the  best  position,  as  a  considerable  part  of  the  disease  results  from  the 
patient  having  an  erroneous  impression  of  when  the 
body  is  in  the  erect  position,  and  education  in  this 
direction  is  most  serviceable.  Again,  the  clothes 
should  be  altered  to  fit  the  patient  when  in  the  "  best 
position  "  ;  this  will  act  as  a  reminder  to  keep  her  in 
position.  As  the  position  improves  the  clothes  are 
further  altered  :  this  has  a  mild  but  constant  restrain- 
ing effect  from  getting  again  into  bad  position. 

Where  the  deformity  is  great  the  question  of 
stronger  measures  must  be  considered,  since  exercises 
alone  will  not  cure  such  cases. 

Where  the  patient  has  to  depend  for  her  living  on 
some  sedentary  occupation,  such  as  needlework,  pain 
may  be  relieved  and  increase  of  deformity  prevented 
to  some  degree  by  the  use  of  plaster-casts  or  poro- 
plastic  jackets  with  steel  supports  moulded  to  fit  the 
patient  when  in  the  best  position.  Such  supports 
must,  however,  be  removable  and  massage  and  exer- 
cises employed  as  well,  or  the  muscles  will  become 
hopelessly  atrophic  and  the  condition  worse  in 
spite  of  the  support.  Of  late  more  severe  measures 
have  been  employed  for  cases  with  great  deformity 
(Abbott).  The  patient  is  forced  into  an  over- 
corrected  position  and  encased  in  plaster  in  this  posi- 
tion. The  plaster  is  cut  away  over  the  side  away  from 
the  gibbus  and  thick,  soft  pads  of  felt  pushed  in 
between  that  prominence  and  the  plaster ;  this  will 
cause  the  chest  to  expand  where  previously  it  was 
concave.  The  correction  must  be  such  that  on  the 
side  away  from  the  gibbus  the  clavicle  is  elevated  till 
instead  of  being  horizontal  it  is  nearly  vertical,  from 
the  over-correction  of  the  shoulder.  Correction  is  said 
to  be  possible  in  three  months  by  this  means  and 
good  results  are  reported.  Of  course,  support  will  be 
needed  in  the  corrected  position  for  some  months  and  exercises  carried  out 
at  the  same  time  to  restore  the  length  and  tone  of  the  affected  muscles 
and  ligaments. 

In  small  children  rickets  is  the  underlying  cause  in  most  instances,  a 
faulty  position  of  carrying  the  child  causing  the  weak  ligaments  and  soft 
bones  readily  to  assume  the  scoliotic  deformity.  In  such  cases  rest  on 
the  back  with  massage  is  indicated,  the  infant  being  kept  in  a  flat  wicker- 


Fig.  185.  Crawling 
exercises  for  scoliosis 
(Klapp).  Note  the 
alternating  flexion  of 
the  spinal  column. 


156  A  TEXTBOOK  OF  SURGERY 

baskel  <>r  in  a  well-padded  plaster  carapace,  ami  crawling  exercises  under 
til  supervision  carried  out  as  soon  as  the  child  is  strong  enough. 
Ill    Tumours  of  the  Spine.    Both  innocent  and  malignanl  Forms  are 

found,   the  latter  being  generally  secondary,   especially  to  cancer  of   the 
breast,  but  primary  sarcomas  also  occur. 

The  signs  resemble  those  of  Pott's  disease,  but  there  is  more  pain  from 
pressure  on  nerve-roots.  The  growth  may  be  localized,  causing  angular 
curvature,  or  diffuse  (cancerous  osteomalacia)  with  crumpling  and  general 
kyphosis  of  most  of  the  spine.  Exploration  may  be  advisable  in  obscure 
primary  cases,  but  where  secondary  to  some  obvious  malignant  focus  else- 
where the  recumbent  position,  mechanical  support,  and  anodynes  are  all 
that  can  be  done. 

DEFORMITIES  OF  THE  NECK 

Under  this  heading  are  described  cervical  ribs  and  torticollis. 

(1)  Cervical  Rib  or  Exostosis  of  the  Seventh  Cervical  Vertebra. 
The  anterior  portion  of  the  transverse  process  of  the  cervical  vertebrae 
represents  a  rib,  and  may  develop  into  a  process  of  abnormal  size  or  even 
into  a  complete  rib  articulating  with  vertebrae  and  sternum.  The  seventh 
vertebra  is  the  one  most  usually  thus  affected,  but  the  sixth  may  also 
present  this  deformity.  Most  usually  the  abnormal  process  is  incomplete, 
articulating  in  front  with  the  first  rib  behind  the  subclavian  groove  by 
a  fibrous  cord,  and  behind  being  either  a  bony  outgrowth  (exostosis) 
of  the  seventh  cervical  vertebra  or  separate  and  articulating  with  it  as  a 
proper  rib.  The  importance  of  this  anomaly  is  its  effect  on  the  brachial 
artery  and  the  lowest  trunk  of  the  brachial  plexus  (first  dorsal  nerve), 
which  are  in  some  manner  compressed  by  the  cervical  rib.  The  relation 
of  the  artery  and  nerve  to  the  rib  is  not  constant,  but  in  many  cases  they 
pass  over  the  abnormal  rib  or  its  fibrous  continuation  and  are  stretched 
over  it.  especially  when  the  arm  is  in  the  pendent  position.  This  accounts 
for  predominance  of  symptoms  in  the  female  sex  (Jones),  in  whom  the 
slope  of  the  shoulder  is  more  downwards  and  allows  such  stretching  to  occur, 
as  well  as  for  the  ease  from  the  pain  obtained  when  the  shoulder  is  elevated, 
as  by  sitting  with  the  upper  limb  on  the  arm  of  an  arm-chair  or  by  increasing 
the  squareness  of  the  shoulder  by  exercises  wTiich  elevate  the  latter.  The 
exostosis  type  is  more  apt  to  cause  trouble  from  pressure  than  the  well- 
developed  accessory  rib. 

Signs.  Although  the  deformity  is  usually  bilateral,  the  symptoms  are 
only  found  on  one  side,  in  most  instances  at  least,  for  some  considerable 
time,  and  most  commonly  in  young  women.  The  symptoms  are  pain 
along  the  inner  side  of  the  arm,  forearm,  and  ulnar  border  of  the  hand  ; 
later  anaesthesia  of  this  area  is  found  and  weakness,  paralysis,  and  wasting 
of  the  intrinsic  muscles  of  the  hand  (supplied  by  the  lowest  trunk  of  the 
plexus  or  first  dorsal  nerve).  Sometimes  vasomotor  signs  are  predominant, 
the  hand  and  forearm  becoming  white  or  cyanosed  ;  this  is  probably  due 
to  pressure  on  the  subclavian  vessels,  is  associated  with  a  feeble  pulse  on 


CERVICAL  RIBS 


457 


the  affected  side,  and  is  relieved  by  elevating  the  arm  or  removing  the 
abnormal  rib.  This  condition  may,  however,  be  due  to  involvement  of  the 
vasomotor  nerves  of  the  plexus. 

Diagnosis.  The  distribution  of  the  pain  and  paresis,  which  is  clearly 
an  affection  of  the  inner  cord  or  first  dorsal  nerve-root,  possibly  feeling 
a  lump  in  the  posterior  triangle  of  the  neck,  and  the  occasional  vaso- 
motor changes  and  weak  pulse  are  suggestive.  A  radiograph  of  the  lower 
cervical  region  will  show  the  anomaly,  though  care  is  needed  not  to  mistake 
an  imperfectly  developed  first  dorsal  rib  for  this  deformity.  The  fact  that 
the  transverse  process  of  the  seventh  cervical  vertebra  is  shorter  and  at 
right  angles  to  the  axis  of  the  body,  while  that  of  the  first  dorsal  is  longer 
and  with  an  upward  tendency,  will  help  in  elucidating  radiographs.  Syringo- 
myelia is  often  confused  with  cervical  rib  (Sherren),  but  attention  to  the 


Fig.  186.     Cervical  rib.     A,  A  large  buttress-like  projection  of  the  seventh  cervical 

vertebra  pressing  on  the  brachial  plexus,  causing  pain  referred  to  the  distribution 

of  the  first  dorsal  nerve  (inner  side  of  forearm  and  hand).      B,  The  same  case  after 

removal  of  the  outer  portion  of  the  "  cervical  rib." 


type  of  anaesthesia  (loss  of  pain,  heat,  cold,  and  not  of  touch)  should  dis- 
tinguish. 

Treatment.  Since  these  anomalies  can  exist  without  symptoms,  it  is 
reasonable  in  the  earlier  and  slighter  cases  to  attempt  to  improve  the  position 
of  the  arm  with  a  view  of  obviating  the  pain.  Exercises  to  increase  the 
power  of  the  shoulder-raising  muscles  and  slinging  the  arm,  while  in  the 
erect  position,  for  some  months  may  be  followed  by  complete  relief,  but  if 
the  pain  persists  and  weakness  of  the  intrinsic  muscles  of  the  hand  is  noted 
or  vasomotor  disturbance  is  present,  it  will  be  advisable  to  remove  the 
abnormal  prominence  before  the  nerves  are  badly  impaired. 

Operation.  The  rib  is  reached  by  an  incision  along  the  border  of  the 
trapezius  in  the  posterior  triangle  ;  the  muscle  is  retracted  backwards  and 
the  process  exposed  at  its  posterior  surface,  for  if  attacked  from  the  front 
there  is  some  risk  of  injuring  the  brachial  plexus  in  dissecting  the  latter  off 
the  cervical  rib  ;  it  is  better  to  divide  the  process  near  its  base  (note,  most 
cases  where  symptoms  are  present  are  those  with  exostoses  and  not  complete 


i:,s  \   TKXTHOOK  OF  Sl'RdKKY 

ribs  witk  articulating  surfaces),  and  then  the  process  is  dissected  carefully 
away  from  the  plexus,  which  is  less  likely  to  be  damaged  in  this  manner 
(Bankart).  In  some  cases  the  first  dorsal  rib,  which  was  undeveloped,  has 
been  removed,  and  with  some  justification,  as  it  w<  raid  appear  to  have  relieved 
the  symptoms. 

(2)  Torticollis  or  Wky-nkck.  By  this  is  meant  flexion  of  the  head 
to  one  side  with  rotation  of  the  face  into  the  other,  caused  by  shortening  of 
the  sternomastoid  muscle  and  not  to  deformities  of  the  neck,  which  may  be 
flexion  or  rotation  in  varying  degree  in  such  conditions  as  spinal  caries. 

Three  main  groups  are  described  :  (a)  the  acute  ;  (b)  the  nervous ; 
(c)  the  fibrous. 

(a)  Acute  Torticollis  is  due  to  tonic  spasm  of  the  sternomastoid,  and  may 
arise  from  several  causes,  such  as  muscular  rheumatism,  reflex  contraction 
due  to  inflamed  glands  or  carious  teeth,  possibly  direct  irritation  of  the 
spinal  accessory  nerve  from  inflamed  glands  or  deep  cellulitis  of  the  neck ; 
Blight  injuries  to  the  muscle  are  a  common  cause.  The  onset  is  sudden, 
the  muscle  being  tense  and  tender,  especially  if  attempts  be  made  to  move 
the  head  :  the  position  of  the  head  and  face  are  as  described  above 

Treatment.  This  depends  on  the  cause.  Deep  suppuration  and  cellu- 
litis of  the  neck  is  the  most  important  and  dangerous  cause,  which  must 
not  be  overlooked,  and  if  found,  promptly  opened  and  drained ;  carious 
teeth  are  removed,  inflamed  glands  opened  or  excised  if  not  yielding  to 
fomentations  (as  usually  happens  in  these  cases) ;  the  rheumatic  type  is 
relieved  by  fomentations  and  soon  passes  off. 

(b)  The  nervous  form  is  described  under  affections  of  the  spinal  acces- 
sory nerve  (See  Nervous  Diseases). 

(c)  Fibroid  Contraction  of  the  Sternotnastoid  (Congenital  Torticollis). 
The  condition  of  the  muscle  is  closely  allied  to  ischsemic  contracture — the 
muscle  being  short,  thin,  fibrous,  and  cordlike.  The  cause  is  uncertain ; 
there  seems  no  evidence  that  rupture  of  the  muscle  at  birth  is  responsible, 
though  the  condition  may  occasionally  follow  the  "congenital  tumour"  of  the 
sternomastoid,  which  is  a  heematoma  due  to  injury.  Most  likely  the  lesion 
is  an  ischseniia  due  to  faulty  position  in  utero,  the  blood-supply  being  cut 
off  in  some  manner.  The  deformity  is  fairly  obvious  and  noted  in  infancy 
or  early  childhood,  but  as  parents  often  suppose  that  the  child  will  "  grow 
out  "  of  the  defect,  it  may  be  years  before  advice  is  sought. 

Signs.  The  head  is  flexed  to  the  side  of  the  short  muscle,  the  face 
rotated  in  the  opposite  direction,  and  the  muscle — especially  its  sternal 
portion — forms  a  thin  cord,  which  becomes  tense  when  the  face  is  rotated 
towards  the  muscle;  the  cervical  fascia  and  carotid  sheath  are  also  con- 
ted. 

Secondary  Deformities.  These  are  seen  to  best  advantage  when  the 
patient  has  remained  untreated  for  several  years.  The  face  and  skull  are 
asymmetrical,  the  former  being  smaller  on  the  affected  (downward-facing) 
side,  the  palpebral  fissure  being  shorter  and  the  cheek  flatter  than  on  the 
opposite  side.   (Fig.  L87.)     The  skull  tends  to  form  a  point  at  the  parieta 


TORTICOLLIS 


459 


eminence  on  the  uppermost  side.  The  asymmetrical  position  of  the  head 
is  compensated  by  bending  the  spine  in  a  contrary  direction,  and  scoliosis 
develops,  which  may  be  considerable  in  old-standing  cases. 

Diagnosis.  The  chronic  painless  nature  of  this  affection  and  the  thin 
cordlike  nature  of  the  tense  sternomastoid  render  it  unlike  any  other 
condition. 

Treatment.  Up  to  two  years  of  age  it  may  be  possible  to  stretch  the 
muscle  by  repeated  passive  and  active  movements  performed  many  times 


Fig.  187.     Facial  asymnietery  secondary  to  torticollis  (lad  of  17).     The  contracted 
sterno-mastoid  on  the  right  side  has  been  divided  and  the  torticollis  corrected. 


daily,  but  in  severe  contracture  or  over  two  years  of  age  it  is  more  satisfac- 
tory to  divide  the  tense  structures  first.  This  should  be  done  by  open 
operation,  as  if  done  efficiently  by  the  subcutaneous  method  the  large 
vessels  are  endangered.  The  lower  end  of  the  sternomastoid  is  exposed 
by  a  horizontal  incision  one  inch  above  the  clavicle,  the  tense  muscle  is 
divided  and  the  head  rotated  so  as  to  bring  into  prominence  the  tense 
portions  of  cervical  fascia,  which  are  carefully  divided  as  they  are  found, 
including  the  carotid  sheath.  When  all  contracted  structures  are  divided 
and  the  movement  of  the  head  is  free,  bleeding-points  are  tied  and  the 
wound  sutured. 

After-treatment  (which  is  most  important)  consists  in  keeping  the  head 
in  the  over-corrected  position  between  sand-bags  till  the  woimd  is  healed, 


460  A  TEXTBOOK  OF  SURGERY 

after  which  passive  and  active  movements  are  carried  out  to  reduce  the 

deformity  and  prevent  the  new-formed  fibrous  tissue  between  the  divided 

muscles  and  fascia  from  contracting  and  causing  recurrence  of  deformity. 

Treatment  for  the  accompanying  scoliosis  should  be  carried  out.     Exer- 

should  be  kept  up  for  a  year  or   more.     In   severe  and   rebellious 

-  -  it  may  be  necessary,  to  prevent  recurrence  of  deformity,  to  employ 

an  apparatus  in  the  shape  of  a  headband  and  corset  with  an  elastic  tractor 

between  to  form  an  artificial  sternomastoid  on  the  sound  side  and  keep  the 

divided  muscle  stretched  ;    in  most  cases  exercises  are  enough,  but  in  any 

they  will  be  needed  as  well  as  an  apparatus. 

AFFECTIONS    OF   THE   UPPER   LIMB 

The  Clavicle.  Congenital.  The  clavicle  may  be  absent  on  one  or 
both  sides,  causing  the  shoulder  to  fall  forwards  and  inwards  with  con- 
siderable narrowing  of  the  width  of  the  shoulders. 

Inflammatory,  (a)  Acute  diaphysitis  may  start  at  the  sternal  end 
(where  is  the  only  epiphysis),  and  stripping  the  periosteum  causes  necrosis 
of  the  whole  diaphysis.     The  superficial  position  renders  diagnosis  easy. 

Treatment.  Free  incision  on  to  the  bone,  which  should  be  opened  if 
the  condition  is  grave.  There  need  be  no  fear  of  removing  the  whole 
diaphysis  early  if  symptoms  are  severe,  as  a  new  clavicle  is  formed  in  a 
tew  weeks  in  young  subjects.  A  three-inch  incision  over  the  centre  of  the 
bone  will  suffice  ;  the  bone  is  divided  and  the  two  parts  twisted  out  sepa- 
rately. 

(b)  Gummatous  inflammation  is  not  uncommon  and  is  likely  to  be  mis- 
taken for  myeloid  sarcoma,  but  X-ray  and  serum  investigation  should  lead 
to  correct  and  early  diagnosis.  If  not  reacting  to  antisyphilitic  treatment 
the  gummatous  part  may  be  scraped  out  and  some  form  of  "  stopping  " 
inserted. 

(c)  The  sterno-clavicular  joint  is  often  affected  in  pyaemia,  the  joint 
becoming  painlessly  distended  with  pus.  Early  opening  and  drainage 
will  result  in  a  movable  joint,  possibly  in  complete  recovery.  In  any  case 
ankylosis  is  practically  unknown  at  this  joint. 

(</)  Tuberculosis  of  this  joint  may  be  found  as  a  chronic  "  white  swelling," 
and  will  probably  heal  well  if  the  arm  of  the  affected  side  be  slung  for  some 
months. 

New  Growths.  The  clavicle  is  one  of  the  seats  of  myeloid  sarcoma 
which  appears  as  a  slowly  growing  tumour,  distending  the  bone;  later  egg- 
shell crackling  will  be  noted.  It  is  distinguished  from  gummatous  tumour 
by  the  more  abrupt  edge  of,  the  swelling  and  the  rarefaction  of  the  bone 

D  in  a  skiagraph. 

Excision  has  been  successful  :  a  supplementary  bone-graft  may  be 
needed.  Periosteal  sarcomas  grow  more  rapidly  and  irregularly  and  do 
not  distend  the  bone  ;    radiograms  will  often  make  the  diagnosis  clear. 

Excision  alone  is  not  satisfactory,  but  followed  by  large  doses  of  X-rays 
or  radium,  and  possibly  (  oley's  Fluid,  the  fatal  termination  may  be  delayed. 


EXCISIOX  OF  THE  CLAVICLE 


461 


Excision  of  the  Clavicle  (for  growth).  An  incision  is  made  the 
whole  length  of  the  bone,  which  is  subcutaneous.  The  acromial  end  is  freed 
first  by  cutting  through  the  conoid  and  trapezoid  ligaments  and  the  trapezius 
and  deltoid  attachments  ;  if  well  away  from  the  growth  the  bone  may  be 
divided,  leaving  the  outer  end  in  place.  The  bone  is  then  carefully  raised, 
dividing  the  muscles  well  away  from  the  bone  and  remembering  that  the 
large  vessels  and  brachial  plexus  are  close  under  the  inner  part.  There 
may  be  difficulty  in  removing  the  inner  end  if  invaded  or  overlapped  by 
growth.  In  such  cases  it  may  be  advisable  to  remove  the  cartilage  of  the 
first  rib  and  part  of  the  sternum  as  well.     As  the  pleura  is  liable  to  be 


Fig.  188.     Sprengel's  deformity,  or  congenital  elevation  of  the  right  scapula. 


wounded  by  this  step  it  will  be  well  in  cases  where  the  growth  is  extensive 
to  employ  intratracheal,  insufflation  anaesthesia. 

The  Scapula,  (a)  Congenital  Defects.  Elevation  of  the  scapula  (Sprengel) 
with  deformity  of  the  bone  is  occasionally  met  with.  The  scapula  is  elevated 
by  contracture  of  the  upper  part  of  the  trapezius,  the  rhomboids,  and  levator 
anguli  scapulae,  so  as  to  lie  partly  in  the  posterior  and  lower  part  of  the 
neck.  The  bone  is  also  altered  in  shape,  so  that  the  vertebral  border, 
instead  of  being  straight,  has  a  mesial  projection  opposite  the  spine  of 
scapula,  which  in  some  instances  forms  a  long  projection  articulating  with 
the  upper  dorsal  or  lower  cervical  vertebral  spines. 

The  cause  is  uncertain  :  intrauterine  pressure  or  ischemic  contracture 
of  the  muscles  may  be  the  underlying  factor  in  causation.  The  result  is 
impaired  movement  of  the  upper  limb,  especially  in  the  upward  direction. 

Treatment.  In  the  earlier  or  slighter  cases  passive  movements  to  improve 
the  position  of  the  scapula  and  lengthen  the  contracted  muscles  may  suffice  ; 
but  in  severe  cases,  where  the  muscles  are  much  shortened,  these  should 


162  A  TEXTBOOK  OF  KURGEKY 

be  divided  by  open  operation  and  movements  continued  when  the  wound 
is  healed.  The  projection  of  the  vertebral  border,  if  long  and  articulating 
with  the  vertebral  spines,  should  be  excised. 

(b)  Winged  Scapula.  In  this  condition  the  lower  angle  of  the  scapula 
stands  away  from  the  side  in  a  "  winged  "  manner.  The  most  marked  cases 
are  due  to  paralysis  of  the  serratus  magnus,  but  minor  degrees  of  this 
deformity  are  noted  in  paralysis  of  the  lower  portion  of  the  trapezius.  The 
condition  is  not  due  to  dislocation  of  the  angle  of  the  scapula  over  the  upper 

of  the  latissimus  dorsi,  as  was  formerly  believed.  Paralysis  of  the 
serratus  magnus  is  due  to  injury  or  other  affection  to  the  nerve  of  Bell  or 
to  the  fifth  and  sixth  cervical  nerve-roots  above  the  origin  of  this  nerve, 
paralysis  of  the  trapezius  to  injuries  of  the  spinal  accessory  or  lower  cervical 
nerves.  These  two  types  of  deformity  are  distinguished  as  follows  :  Where 
the  serratus  is  paralysed  the  winging  is  much  more  marked,  and  if  the 
patient  tries  to  bring  the  scapula  forward,  as  in  pushing  the  arm  forward 
to  its  full  extent,  the  winging  becomes  more  marked  and  the  power  of  such 
a  push  is  very  small ;  where  the  winging  is  due  to  paralysis  of  the  lower 
trapezius  the  deformity  is  diminished  by  this  movement  and  the  power  of 
pushing  the  arm  forward  is  good. 

Treatment.  Attempts  should  be  made  to  unite  these  nerves  by  opera- 
tion if  divided,  while  nutrition  of  the  muscles  is  maintained  by  massage. 
Where  nerve-suture  fails  some  form  of  nerve-anastomosis  may  be  considered 
or  the  clavicular  part  of  the  pectoralis  major  attached  to  the  vertebral 
border  of  the  scapula,  to  take  the  place  of  the  serratus.  This  measure  has 
been  fairly  successful. 

(c)  Acute  and  chronic  infections  of  the  scapula  are  not  common,  and 
the  treatment  is  on  the  general  lines  already  laid  dowm 

(d)  New  Groivths.  The  scapula  is  the  seat  of  tumours  both  innocent  and 
malignant,  including  exostoses,  myeloid  and  periosteal  sarcomas,  the  nature 
of  which  is  distinguished  by  the  rate  and  uniformity  or  otherwise  of  growth 
and  tumour-formation.  Invasion  of  neighbouring  structures  both  super- 
ficial and  deep,  as  well  as  of  the  axillary  glands,  will  often  afford  good 
evidence  of  malignancy,  while  radiographs  will  often  help  in  doubtful 
cases. 

Treatment.  Excision  is  indicated,  which  will  be  local  in  cases  of  exostoses 
and  myeloid  growths,  complete  in  the  case  of  sarcomas,  unless  the  spread 
is  too  far  advanced  for  this  measure  to  be  worth  while. 

Excision  of  the  Scapula,  (a)  Partial,  for  Innocent  Growths  or  Localized 
Caries  or  Necrosis.  This  operation  will  depend  on  the  position  of  the 
growth  or  of  the  sinuses  leading  from  the  necrosed  area,  so  that  no  set 
operation  can  be  described.  Each  case  will  have  to  be  dealt  with  so  as  to 
arrive  at  the  seat  of  disease  conveniently  and  with  as  little  damage  to 
muscles,  vessels,  and  nerves  as  possible.  The  body  may  be  reached  from 
behind,  the  coracoid  and  glenoid  regions  via  the  axilla. 

(h)  Complete  excision  is  indicated  for  malignant  growths  which  are 
still  localized  in  the  scapula  (where  the  axilla  and  humerus  are  involved  the 


EXCISION  OF  THE  SCAPULA  46 

interscapulo-thoracic  amputation  will  be  needed  if  operative  measures  are 
contemplated). 

Haemorrhage  is  the  main  trouble  in  this  operation,  and  it  is  well  to  secure 
the  large  subscapular  artery  early  in  the  proceedings  (Cheyne)  by  a  longi- 
tudinal incision  over  the  vessels  in  the  axilla,  the  anterior  fold  of  which  is 
raised,  the  axillary  vessels  exposed,  and  the  subscapular  artery  tied  near 
its  origin.  Through  this  incision  the  muscles  attached  to  the  coracoid 
process  (biceps,  coraco-brachialis,  and  pectoralis  minor)  are  also  divided  ; 
the  incision  is  then  closed  and  the  patient  turned  over  on  the  face.  A 
T-shaped  incision  of  good  size  is  made  over  the  body  of  the  scapula  ;  the 
T  may  be  vertical  or  horizontal,  with  the  cross-stroke  along  the  upper  or 
vertebral  border  of  the  bone.  The  flaps  thus  marked  out  are  turned  up 
and  the  mass  exposed.  The  arm  is  pulled  away  from  the  side  and  the 
deltoid  and  trapezius  divided  well  away  from  the  bone ;  the  rhomboids 
and  levator  anguli  are  divided  and  the  posterior  scapular  Vessels  tied  ; 
the  serratus  magnus  is  divided  and  the  omohyoid,  the  suprascapular  vessels 
being  tied  at  this  point.  The  acromio-clavicular  joint  must  be  now  con- 
sidered :  if  possible,  the  joint  should  be  spared,  the  acromion  being  divided 
and  left  behind,  as  this  will  give  a  more  useful  arm  ;  but  it  may  be  necessary 
to  disarticulate  through  this  joint  or  even  remove  the  outer  part  of  the 
clavicle  as  well.  The  spinati  are  next  divided,  the  vertebral  border  of 
the  scapula  dragged  from  the  side  and  the  latissimus  dorsi,  biceps,  triceps, 
and  teres  major  divided.  The  wound  is  closed,  being  drained  for  twenty- 
four  hours.  The  resulting  limb  is  fairly  useful  and  strong  except  for  move- 
ments above  the  level  of  the  shoulder.  The  ultimate  results  of  excision 
for  malignant  growth  are  poor  (Xancrede)  ;  60  per  cent,  are  dead  in  two 
and  a  half  years  and  complete  cure  is  only  to  be  expected  in  10  per  cent,  of 
cases. 

THE  SHOULDER  REGION 

Dislocations  and  inflammations  are  found  in  this  situation. 

(a)  Dislocations.  Apart  from  those  due  to  violence,  dislocations  here 
are  due  to  congenital  defects  and  paralysis. 

Congenital  dislocation  of  the  shoulder- joint  is  rare  compared  with  that 
of  the  hip.  The  glenoid  fossa  is  deformed  or  absent  and  the  displacement 
of  the  humerus  may  be  forward  or  backward.  Movement  is  considerably 
impaired.  Reduction  by  manipulation  may  be  possible  or  operative  measures 
indicated  in  suitable  cases. 

Paralytic  dislocations  and  subluxations  are  far  more  common,  and  result 
from  birth  palsy  of  the  Erb  type,  in  which  there  is  injury  of  the  fifth  cervical 
nerve-root.  As  a  result  of  the  paralysis  the  deltoid,  spinati  and  biceps 
atrophy  and  become  overstretched,  the  weak  capsule  of  the  joint  cannot 
retain  the  head  of  the  bone  in  position  and  elongates,  with  the  result  that 
subluxation  and  finally  dislocation  follows. 

Signs.  The  arm  is  in  the  usual  Erb-position,  hanging  by  the  side  and 
rotated  inwards,   th'    deltoid  and  spinati   being  atrophic,   the  acromion 


l.il  A  TEXTBOOK  OF  SURGERY 

prominenl  :  there  will  he  a  gap  of  some  extent  Let  ween  this  prominence  and 
the  head  of  the  hone.  The  joinl  is  of  the  "flail"  variety,  and  this  inter- 
feres with  use  of  the  hand,  which  is  generally  in  good  condition. 

Treat  ment.  (1)  Part  of  the  trapezius  has  been  transplanted  into  the 
deltoid  insertion,  the  arm  being  put  up  in  an  abducted  and  everted 
position. 

(2)  Arthrodesis  of  the  joint  may  be  done,  the  cartilage  being  removed 
from  the  glenoid  fossa  and  head  of  the  humerus,  and  the  bones  united  with 
peg  or  screw  in  a  position  of  horizontal  abduction  and  inversion  of  the 
humerus,  so  that  the  hand  can  be  raised  to  the  mouth.  The  former  plan, 
if  feasible,  would  appear  to  be  the  more  perfect,  and  in  any  case  will  not 
interfere  with  arthrodesis  later  should  it  fail  to  give  satisfaction. 

(b)  Inflammations  and  Infections.  (1)  Acute  inflammation  may 
result  from  injury,  punctured  wounds,  gonorrhoeal  or  pysemic  infection, 
as  well  as  'rheumatism,  and  commences  as  synovitis,  possibly  progressing 
to  arthritis,  according  to  the  virulence  of  the  infection  and  the  efficacy  of 
treatment  adopted.  Effusion  into  the  shoulder- joint  causes  pain  and 
tenderness  when  the  joint  is  moved  in  any  direction  ;  the  shoulder  region 
appears  full  and  fluctuation  may  be  obtained  under  the  deltoid  and  some- 
times in  the  axilla.  If  suppuration  takes  place  the  abscess  may  point  in 
front  or  behind  the  deltoid. 

Treatment  depends  on  the  variety  and  severity  of  the  inflammation. 
Rest  by  slinging  the  arm,  and  later  massage,  will  be  enough  in  the  milder 
cases,  while  arthrotomy,  drainage,  and  washing  out  the  joint  is  needed  in 
acute  infections  and  occasionally,  where  very  severe,  excision  of  the  head 
of  the  humerus. 

(2)  Tuberculosis  of  the  Shoulder-joint.  This  is  found  usually  in  adults, 
seldom  in  children.  The  lesion  may  originate  in  the  head  of  the  humerus, 
occasionally  in  the  glenoid  fossa,  while  synovial  infection  is  rarely  the  start- 
ing-point and  great  effusion  into  the  joint  is  uncommon.  Often  the  disease 
is  quiet  with  but  little  pain  :  the  joint-surfaces  are  destroyed  and  ankylosis 
results.  In  other  examples  there  may  be  considerable  destruction  of  bone, 
suppuration,  starting-pains  at  night,  and  formation  of  extra-articular 
abscesses,  which  come  to  the  surface  at  either  border  of  the  deltoid  or 
gravitate  down  the  arm,  following  the  long  tendon  of  the  biceps,  forming 
one  variety  of  Baker's  cyst. 

Signs.  Pain  is  variable ;  wasting  of  the  deltoid  and  spinati,  with 
rigidity  of  the  joint  in  all  directions,  is  usual  (care  is  needed  in  estimating 
fixation  of  the  shoulder,  as  movements  of  the  scapula  on  the  trunk  will 
be  taken  for  movements  of  the  joint ;  the  scapula  must  be  held  fast  while 
testing  the  joint).  Later  there  may  be  firm  ankylosis  or  abscess-formation, 
and  sometimes  dislocation  of  the  head  of  the  humerus. 

Diagnosis.  From  osteo-arthritis,  which  is  common  in  this  joint,  the 
slighter  limitation  of  movement  and  less  muscular  wasting  of  the  latter 
affection,  as  well  as  its  greater  chronicity  and  alterations  with  the  weather, 
will  distinguish.     Wasting  of  the  deltoid  and  spinati  in  nerve  lesions  is 


TUBERCULOSIS  OF  THE  SHOULDER  165 

distinguished  by  the  freedom  of  movement  of  the  joint,  which  may  be 
"  flail-like,"  and  by  the  reaction  of  degeneration  in  the  muscles. 

From  disease  of  the  subdeltoid  bursa  by  the  slight  affection  of  mobility 
in  the  latter  affection,  by  the  swelling  being  confined  to  the  upper  part  of 
the  shoulder,  and  by  radiograms  which  show  a  normal  joint. 

From  tumours  of  the  upper  end  of  the  humerus  diagnosis  is  made  by 
the  freedom  of  the  joint  movements  in  the  early  stages  of  the  latter  disease, 
and  above  all,  in  the  early  stages,  by  radiograms. 

Treatment.  The  arm  should  be  fixed  in  the  position  of  horizontal 
abduction  and  inversion  (the  best  position  for  ankylosis,  which  is  to  be 


Fig.  189.     Osteoarthritis  of  the  shoulder,  showing  considerable  deformity  of  the 

head  of  the  humerus. 

expected)  by  a  large  spica-plaster  or  a  jacket  with  suitable  outrigger  for 
the  arm.  The  arm  should  not  be  allowed  to  become  ankylosed  when  hanging 
at  the  side  or  all  movement  above  the  horizontal  will  be  lost.  The  joint- 
should  be  examined  frequently  to  see  if  abscess-formation  has  occurred. 
When  the  condition  is  rapidly  progressing  and  the  head  of  the  humerus  is 
certain  to  be  destroyed,  healing  may  be  accelerated  by  a  timely  excision. 

(3)  Rheumatoid  Affections.  Osteo-arthritis  is  common  in  the  shoulder 
and  neuropathic  arthritis  not  uncommon,  especially  in  syringomyelia,  but 
also  in  tabes. 

(4)  Effusion  into  the  subdeltoid  bursa  may  be  due  to  acute  or  chronic 
inflammation  and  resembles  similar  affections  of  the  shoulder- joint,  but  is 

i  30 


166  A  TEXTBOOK  OF  SURGERY 

distinguished  by  absence  of  pain  on  rotating  the  humerus  in  its  socket  and 
absence  of  swelling  in  the  axilla.  Treatment  is  on  similar  lines,  viz.  test, 
counter-irritants,  and.  later,  massage  in  the  milder  conditions:  incision 
and  drainage  if  suppuration  has  taken  place. 

(c)  Ankylosis  of  the  Shoulder.  This  usually  results  from  tubercle, 
but  also  from  gonorrhoea)  infection,  osteo-arthritis,  &c.  Movement  of  the 
arm  is  permitted  a>  Ear  as  the  horizontal  by  movement  of  the  scapula  on 
the  body,  but  no  further  unless  the  limb  has  been  put  up  in  the  horizontal 
position  and  so  arikylosed,  when  more  abduction  will  be  possible. 

Treatment.  It  is  often  questionable  whether  an  ankylosed  shoulder 
should  be  interfered  with;  certainly  not  much  bone  should  be  removed  from 
the  upper  end  of  the  humerus,  or  the  fulcrum  for  the  action  of  the  deltoid  in 
abduction  will  lie  lost.  Any  operative  treatment  here  should  be  confined 
to  freeing  the  ankylosis  and  placing  a  strip  of  fascia  into  the  gap  to  prevent 
ankylosis  recurring  (arthroplasty). 

Operations  at  the  Shoulder-joint.  The  patient  is  in  the  supine 
position  in  all  these  operations. 

(1)  Aspiration  (for  diagnostic  purposes).  A  needle  may  be  passed  into 
the  joint  b)'  thrusting  it  horizontally  backwards  just  below  the  coracoid 
process  till  it  meets  the  bone. 

(2)  Arthrotomy  (for  exploration  and  drainage).  The  shoulder-joint  is 
reached  by  a  vertical  incision  about  three  inches  long  down  from  the  coracoid. 
The  deltoid  is  retracted  outwards,  the  coraco-brachialis  and  short  head  of 
biceps  inwards,  and  the  capsule  of  the  joint,  formed  largely  of  the  tendon  of 
the  subscapulars  exposed.  The  joint  is  opened,  taking  care  not  to  injure 
the  long  tendon  of  the  biceps,  which  is  to  the  outer  side  of  the  incision.  The 
joint  may  simply  be  drained,  or  the  opening  may  be  enlarged  and  the 
interior  of  the  joint  explored  ;  if  necessary  excision  may  be  performed. 

(3)  Excision  of  the  Shoulder.  By  this  is  meant  removal  of  the  upper 
end  of  the  humerus,  the  glenoid  fossa  being  as  a  rule  not  touched.  The 
operation  is  indicated  (a)  for  myeloid  sarcoma  of  the  upper  end  of  the 
humerus;  (f>)  for  tuberculosis  when  advancing  rapidly;  (c)  in  acute 
infective  conditions  when  drainage  of  the  joint  alone  is  insufficient ;  (d)  for 
ankylosis  the  operation  will  be  rather  an  arthroplasty;  (e)  for  compound 
comminuted  fracture  of  the  head  of  the  humerus  ;  (/)  occasionally  for 
old-standing,  irreducible  dislocations  where  reduction  by  operative  measures 
fails. 

'I  he  joint  is  approached  by  an  incision  similar  to  that  used  in  exploration 
but  longer,  starting  above  at  the  clavicle,  passing  over  the  coracoid  process, 
splitting  the  inner  fibres  of  the  deltoid  nearly  to  their  insertion.  The 
deltoid  and  pectoralis  major  are  retracted  out  and  inward  respectively, 
the  long  tendon  of  the  biceps  identified  and  lived,  and  the  joint  opened 
internal  to  thifl  and  its  Interior  inspected.  If  it  be  decided  to  perform  a 
formal  excision  the  capsule  is  opened  more  widely,  the  tendon  of  the  biceps 
retracted  inwards,  the  external  and  internal  rotator  muscles  are  cut  away 
i  tie-  head,  which  is  rotated  inwards  and  outwards  alternately  to  render 


EXCISION  OF  THE  SHOULDER 


4  I  u 


this  more  easy.  The  head  of  the  bone  can  then  be  protruded  from  the 
wound  and  removed  with  the  saw  as  far  as  disease  extends.  Any  diseased 
synovial  membrane  is  dissected  away,  as  well  as  the  sheath  of  the  biceps- 
tendon  if  affected  ;  the  glenoid  fossa  is  examined  and  gouged  out  if  neces- 
sary. When  all  diseased  material  has  been  removed  the  muscles  are  brought 
together  and  the  wound  closed,  being  drained  for  thirty-six  to  forty-eight 
hours.  If  possible  the  bone  should  be  divided  through  the  anatomical  neck  ; 
the  classic  operation  consists  in  division  of  the  surgical  neck,  which  usually 
means  a  very  weak  arm. 

The  above  is  the  type  of  operation  suitable  for  massive  tubercle  or  severe 
necrosis  (pyogenic)  ;  in  less  severe  instances  curetting  the  bone  and  removal 
of  diseased  synovial 
membrane  may  suffice  ; 
in  fractures,  removal  of 
loose  fragments  and 
rounding  of  rough  sur- 
faces ;  in  ankylosis. 
division  of  adhesions, 
removal  of  only  a  small 
amount  of  bone,  and 
interposition  of  a  strip 
of  fascia  and  fat  will 
be  indicated. 

After  operation  the 
limb  is  fixed  in  the 
horizontal  position,  and 
three  weeks  later  mas- 
sage and  gentle  pas- 
sive movements  com- 
menced, but  with  great 
caution  in  tuberculous  cases;  indeed,  in  these  cases  it  will  be  safer  to 
wait  for  some  months  before  commencing  movements,  as  it  is  impossible 
to  be  certain  of  removing  all  the  disease,  and  movements  may  cause  the 
affection  to  light  up  again. 

The  results  of  the  classic  excision  are  disappointing,  movement  in  most 
instances  being  only  possible  for  actions  below  the  horizontal ;  in  a  few 
cases,  however,  good  movement  of  the  arm  above  the  head  is  obtained. 
For  this  reason  removal  of  as  little  bone  as  possible  is  advocated  unless 
the  extent  of  the  disease  obliges  a  wide  removal. 

Kocher's  plan  of  approaching  the  joint  from  behind,  temporarily 
resecting  the  spine  and  acromion  of  the  scapula,  and  reflecting  these 
with  the  deltoid,  after  dividing  the  insertion  of  the  trapezius,  is  well 
reported.  The  joint,  after  being  thus  exposed,  is  opened  by  dividing  the 
external  rotator  tendons.  A  very  good  exposure  of  the  glenoid  f<>>sa  and 
head  of  the  humerus  is  obtained  and  the  subscapularis  may  not  need 
division. 


Pig.  L90.     skin  incision  for  Spence's  racket  amputation 

at  the  shoulder- joint. 


\  TEXTBOOK  OF  SURGERY 

(I)  Amputation  at  the  Shoulder-joint.  This  is  indicated  in  ('/)  severe 
injuries  e.g.  as  compound  comminuted  fractures  with  injury  to  the  main 
vessels  such  as  result  from  railway  smashes,  gunshot  and  shell  wounds.  &c., 
though  it  is  surprising  in  whal  severe  cases  of  this  sorl  the  limb  can  be  saved 
by  careful  practice  of  ;i-.]>sis. 

(b)  In  genera]  toxaemia  from  gross  infections  —whether  of  the  soft  tissues, 
as  in  acute  spreading  emphysematous  cellulitis  and  gangrene,  or  in  acute 
diaphysitis  where  drainage  or  diaphysectomy  alone  fails  to  improve  the 
condition  of  the  patient,  or  if  severe  secondary  haemorrhage  occurs  in  such 
conditions. 

(c)  In  chronic  infections  (tubercle)  where  excision  fails  and  hectic  fever 
and  lardaceous  disease  threaten  the  patient's  life. 

(i!)  For  sarcoma  of  the  humerus  if  not  too  high  (in  sarcoma  of  the  upper 
end  of  the  bone  the  whole  limb  with  the  scapula  will  need  to  be  sacrificed). 

(e)  In  cases  of  axillary  aneurysm  where  the  sac  is  leaking  or  gangrene 
threatened. 

( /)  In  cases  of  elephantoid  arm  due  to  the  solid  oedema  caused  by  recur- 
rence of  cancer  of  the  breast  in  the  upper  axilla  (but  here  also  removal  of 
the  entire  limb  will  probably  lie  the  operation  of  choice  if  any  be  attempted). 

Amongst  the  numerous  operations  devised  by  the  ingenuity  of  anato- 
mists one  stands  out  as  pre-eminently  practical,  viz.  that  by  anterior  racket 
incision  (Spence),  which  has  the  advantage  of  exposing  the  joint  for  exami- 
nation and  of  reaching  the  vessels  so  that  they  can  be  tied  early  in  the 
operation  if  the  surgeon  is  short-handed.  The  amputation  is  commenced 
by  an  incision  from  the  coracoid  down  through  the  anterior  fibres  of  the 
deltoid  to  a  point  opposite  its  insertion  (as  in  excision),  separating  the  deltoid 
and  pectoralis  major.  From  the  lower  end  of  this  incision  another  is  carried 
round  the  limb,  cutting  the  skin  only  for  the  inner  part  of  its  course  but 
dividing  the  deltoid  insertion  down  to  the  bone.  The  soft  parts  to  the 
outer  side  of  the  incision,  including  the  deltoid,  are  retracted  outwards 
and  the  joint  displayed  ;  the  capsule  is  opened  and  the  rotator  tendons 
cut  away  from  the  tuberosities,  the  biceps  tendon  being  divided.  The 
head  is  disarticulated  and  pushed  forward  out  of  the  wound,  the  surgeon 
running  his  knife  down  behind  the  bone.  Before,  however,  the  knife  cuts 
through  the  tissues  to  the  inner  side  of  the  bone  into  the  shallow  skin  incision 
there  the  assistant  slides  his  thumbs  behind  the  knife  and  grasps  the  tissues 
on  the  inner  part  of  the  longitudinal  incision  between  the  thumbs,  which 
are  inside  the  wound,  and  the  fingers,  which  are  outside,  on  the  outer  wall 
of  the  axilla,  thus  compressing  the  great  vesseh,  till  the  surgeon  has  divided 
the  inner  part  of  the  soft  tissues  picked  up  and  tied  these  vessels.  If  there 
is  do  adequate  assistant  the  inner  part  of  the  circular  incision  is  deepened 
and  the  vessels  found  and  divided  between  ligatures  before  the  head  is 
disarticulated  and  the  operation  concluded  as  before.  Besides  the  main 
els  there  will  be  a  few  bleeding-points  to  be  tied  in  the  outer  part  of 
the  incision.  The  wound  is  closed  and  drained  for  twenty-four  hours. 
Operating  in  this  manner  there  will  be  no  need  for  tourniquets  or  other 


AMPUTATION  OP  THE  ENTIRE  TTPER  LIMB  400 

SLtSf" TWe'8i '"^ tneanterior 

(•->)  Amputation  of  the  Entire  Vviin-  r;,„h  it 
thoracic  amputation  of  Berger)     Tfc  i,       '  (*B?frt«.  inte*<*P*Io- 

/■     mis  is  indicated  for  severe  compound 


;""° ' v'""  '•""■" -> ~t; v:;;"',;:>::-;;,»i;;;:-t;r 

fractures  of  the  humerus  and  scapula  ahnvo  <4,o 

at  the  shoulder-iomt  will  suZf  ■£ lZ Z? " ^* '"'^ 
in  the  humerus  (sarcoma)  or  of  the  canuh h  J!  ?i  gI0Wtha  hi-h 
-  eauecr  of  the  hreast  reLmg  S,  $?*£**  ^ 


t70  A  TEXTBOOK  OF  SURGERY 

great  pain  ;  less  often  for  infective  conditions  and  gangrene.  The  main 
vessels  are  secured  early  so  that  there  is  no  greal  bleeding.  The  arm, 
scapula,  ami  three-fourths  of  the  clavicle  arc  removed. 

Operation.  The  patient  lying  on  his  back,  an  incision  is  made  the 
whole  length  of  the  clavicle  ;  the  fascia  and  pectoralis  major  are  separated 
from  the  bone  and  the  latter  divided  with  Gigli's  saw  just  inside  the  coraco- 
clavicular  ligaments  and  just  outside  the  rhomboid  ligament ;  the  inter- 
vening portion  of  bone  is  removed,  taking  care  of  the  vessels  lying  under  it 
(wide  removal  of  the  clavicle  is  important).  The  subclavius  muscle  is 
divided  and  the  vessels  lied  and  divided  at  the  outer  border  of  the  first 
rili.  the  artery  being  secured  first  and  the  limb  elevated  before  the  vein  is 
ligatured  in  older  to  avoid  loss  of  blood.  The  distal  parts  of  the  vessels 
arc  secured  with  clamps  to  avoid  regurgitation  of  blood  and  the  vessels 
divided  between  the  clamp  and  ligature.  The  posterior  scapular  and  supra- 
scapular arteries  may  preferably  be  tied  through  this  incision. 

Next,  the  arm  being  drawn  away  from  the  side,  a  second  incision  is 
carried  from  the  middle  of  the  first  down  and  back  to  the  lower  angle  of  the 
scapula,  cutting  through  the  pectoralis  dividing  the  brachial  plexus,  which 
may  be  infiltrated  with  novacain,  while  the  glands  and  fat  are  swept  out 
of  the  axilla.  This  incision  will  cross  the  lower  part  of  the  axilla.  The 
third  incision  is  made  with  the  arm  and  scapula  drawn  away  from  the 
trunk,  and  if  the  patient  is  well  over  the  edge  of  the  table  there  is  no  need 
to  turn  him  over.  This  incision  runs  from  the  outer  end  of  the  first,  i.e. 
the  outer  end  of  the  clavicle  over  the  acromion  to  the  lower  angle  of  the 
scapula,  where  it  joins  the  second.  The  skin  and  superficial  fascia  are 
reflected  to  the  vertebral  border  of  the  scapula,  which  is  made  easier  by 
putting  the  arm  across  the  body  and  retracting  this  flap  and  the  pectoro- 
axillary  flap  in  front ;  the  attachments  of  the  scapula  to  the  body  are  divided 
—  viz.  the  trapezius,  rhomboids,  levator  anguli,  and  the  serratus  magnus. 
The  amputation  is  now  complete.  In  the  last  stage  the  posterior  scapular 
and  suprascapular  vessels  will  be  cut,  and  bleed  if  not  caught  in  the  first 
stage.  Other  abnormal  and  anastomotic  vessels  will  need  ligature.  The 
muscles  should  be  cut  as  far  as  possible  from  the  bones  if  the  operation  is 
for  malignant  growth.  The  large  wound  is  then  closed  and  drained  for 
twenty-four  hours. 

AFFECTIONS  OF  THE   HUMERUS 

(a)  Acute  diaphysitis  is  not  uncommon,  usually  starting  at  the  upper 
end.  leading  to  stripping  of  the  periosteum  and  necrosis  of  more  or  less  of 
the  shaft,  possibly  causing  suppurative  arthritis  of  the  shoulder-joint.  In 
searching  for  subperiosteal  abscess  in  such  cases  the  incision  should  be 
made  at  "the  point  of  maximum  swelling,  if  any  be  present,  for  if  explored 
it  the  best  anatomical  places  the  focus  may  be  missed.  When  acute  bone 
disease  is  present  without  local  swelling  the.  upper  part  can  be  explored 
by  an  incision  similar  to  that  employed  for  exploring  the  shoulder- 
joint  :   the  lower  end  can  be  reached  by  an  incision  just  behind  the  external 


THE  HUMERUS  AXD  ARM  471 

intermuscular  septum,   below   and   behind   the   crossing   of  the   musculo- 
spiral  nerve. 

(b)  Tuberculosis  of  the  shaft  occurs  in  young  children  with  rarefaction 
and  cavitation  of  the  bone,  ending  in  cold-abscess  formation  ;  these  may- 
be attacked  with  a  view  to  bone-stopping,  &c,  by  similar  incisions  to  the 
above 

(c)  Gummatous  osteomyelitis  is  found  in  adults. 

(d)  The  upper  third  of  the  shaft  is  one  of  the  places  where  cyst-formation 
from  osteitis  fibrosa  cystica  occurs. 

(e)  Of  new  growths  both  myeloid  and  periosteal  sarcomas  are  found. 
For  periosteal  sarcoma  if  low  down,  amputation  at  the  shoulder  may  be 
permitted,  but  if  near  the  upper  end  the  whole  limb  and  scapula  must  be 
sacrificed  if  operative  treatment  be  undertaken,  but  the  results  are  not 
good.  For  myeloid  sarcoma  erasion  and  bone-stopping  or  excision  and 
grafting  are  indicated. 

Amputation  through  the  Humerus.  This  is  indicated  for  severe 
crushes,  rapidly  spreading  infection  or  gangrene,  especially  with  secondary 
haemorrhage  and  for  malignant  tumours  of  the  forearm  where  resection 
seems  inadequate. 

rI  he  operation  should  be  done  if  possible  below  the  upper  third,  or  the 
resulting  stump  will  be  too  short  to  be  much  use  for  an  artificial  arm. 

Operation.  The  circular  method  is  useful  here,  the  skin  being  divided 
by  a  sweep  of  the  knife,  the  biceps  cut  level  with  the  skin,  as  it  retracts 
so  freely:  the  skin  and  muscle  retracted  without  eversion  (i.e.  made  to 
slide  up  the  bone),  the  triceps  and  brachialis  divided  by  a  second  circular 
cut  down  to  the  bone  and  again  retracted  and  cut  as  before,  the  bone  is 
then  divided.  The  vessels  to  be  tied  are  the  brachial,  lying  at  the  inner 
border  of  the  biceps,  the  superior  profunda  and  inferior  profunda  lying 
respectively  close  to  the  external  and  internal  intermuscular  septa.  The 
median,  ulnar,  musculo-spiral,  and  internal  cutaneous  nerves  will  be  dis- 
serted and  divided  high  up.  The  suture-line  runs  in  an  antero-posterior 
direction. 

The  Region  of  the  Elbow,  (a)  Deformities.  Alterations  of  the 
"  carrying-angle  '"  known  as  cubitus  varus,  or  bowing-out.  and  cubitus 
valgus,  or  bowing-in  of  the  joint,  are  not  uncommon  as  the  result  of 
improperly  set  fractures  or,  more  often,  from  separations  of  the  lower 
epiphyses  of  the  humerus.  These  deformities,  though  unsightly,  seldom 
cause  any  great  disability,  though  pressure  on  the  ulnar  nerve  is  recorded 
(Sherren),  resulting  many  years  after  injury  which  has  caused  cubitus 
valgus. 

Treatnu  nt.  This  is  only  needed  where  there  is  disability  or  pressure  on 
the  ulnar  nerve,  when  osteotomy  of  the  lower  end  of  the  humerus  is  per- 
formed and  the  fragments  placed  in  correct  position. 

(/>)  Congenital  D'slocation,  or  absence  of  the  head  of  the  radius,  is  likely 
to  interfere  with  the  actions  of  pronation  and  supination,  and  in  such 
instances  the  head,  if  causing  the  trouble,  may  be  excised,  though  too 


(72  \    rEXTBOOK  OF  SURGERY 

much  musl   aol   be  expected  from  iliis.  as  there  is  often  contracture  of 
muscles  and  ligaments  as  well. 

Inflammations.  Effusion  into  the  joinl  is  most  marked  al  either 
side  of  the  olecranon  and  lower  end  of  the  triceps  tendon  on  the 
posterior  surface,  also  to  a  less  degree  some  fullness  of  the   antecubital 


VARUS  NORMAL  VALGUS. 

Fig.  L92.     Deviation  at  the  elbow,  the  result  of  injuries  to  the  lower  epiphysis  of 

i  he  humerus. 

fossa  may  be  noted.  When  there  Is  effusion  the  joint  is  slightly  Hexed  and 
semi-]  donated. 

(1)  Acute  inflammation  may  be  from  spread  of  osteitis  or  acute  suppu- 
ration of  the  olecranon  bursa,  and  from  pyaemia,  gonorrhoea,  or  ordinary 
rheumatism. 

The  milder  cases  will  recover  on  slinging  the  arm  with  a  flexed  elbow  ; 

where  severe  infection  is  presenl  the  joint  must  be  opened  ather  side 

of  the  olecranon  and  drained. 


TUBERCULOSIS  OF  THE  ELBOW 


473 


(2)  Tuberculosis  of  the  Elbow.  This  may  originate  in  the  olecranon,  the 
lower  end  of  the  humerus,  or  the  synovial  membrane.  In  the  latter  ease  the 
onset  is  insidious.  The  power  of  extension  of  the  joint  being  gradually  lost, 
and  later  a  "  white  swelling  "  about  the  joint,  increased  fixity  and  muscular 
wasting  are  found.  When  starting  in  the  bones  with  erosion  of  cartilage 
there  may  be  starting-pain  at  night  early,  and  little  swelling  at  first  but 
evidence  of  caries  on  a  radiograph.  When  the  condition  is  well  developed 
the  fixed  elbow,  fusiform  swelling  about  the  joint,  wasted  biceps,  triceps. 
and  forearm  present  a  characteristic  picture.  When  suppuration  occurs 
sinuses  may  form  on  either 
side  of  the  olecranon  or 
over  the  head  of  the  radius. 

Treatment.  Immobili- 
zation in  a  splint  of  leather 
poroplastic  or  plaster  of 
Paris  in  the  semi-pronated 
and  flexed  position  should 
be  arranged.  The  flexion 
should  be  to  rather  less 
than  a  right  angle  (as  the 
most  useful  position  for 
ankylosis).  This  will  result 
in  healing,  where  condi- 
tions are  favourable,  in 
from  six  to  twelve  months. 
If  not  healing  in  this  time 
or  if  advancing  rapidly, 
causing  much  disorganiza- 
tion of  the  joint  and  spread 
of  infection  along  the  bones, 
operative  measures  are  ad- 
visable.    The  joint  may  be 

entered  by  making  a  long  posterior  incision  and  dividing  the  base  of  the 
olecranon;  this  is  turned  upward  and  the  interior  of  the  joint  inspected. 
If  only  the  synovial  membrane  and  perhaps  the  surface  of  the  cartilage 
as  well  are  affected,  the  operation  will  be  continued  as  an  arthrectomv. 
removing  synovial  membrane  and  gouging  out  diseased  bone.  The  radio- 
ulnar joint  should  be  examined  and  any  diseased  tissue  cleared  away.  When 
;ill  disease  is  removed  the  olecranon  is  seemed  in  position  again  and  the 
wound   closed.     In  favourable  cases  a  movable  elbow  may  result. 

Where  the  disease  is  more  widespread  a  formal  excision  will  be  n led. 

The  lateral  ligaments  are  divided,  the  lower  end  of  the  humerus  dislocated 
out  and  removed.  The  upper  end  of  the  radius  and  the  corresponding:  part 
of  the  ulnar  is  cleared  and  removed  ;  all  diseased  synovial  membrane  is 
removed  and  the  wound  closed. 

The  amount  of  bone  to  remove  is  rather  a  vexed  question.     If  enough 


Fig.  193.     Tuberculosis  in  the  olecranon  process  ;  arrow 
points  to  rarefied  area.     Solid  grey  growth  without  sup- 
purated.    Boy  sel .  9. 


171  A  TEXTBOOK  OF  SURGERY 

be  excised  to  ensure  a  freely  mobile  joint,  i.e.  I'  t<>  2  in.  from  both 
ulna  and  humerus,  there  is  some  chance  of  a  flail-joint  resulting,  and 
in  the  ease  of  young  subjects  growth  will  certainly  be  interfered  wit h.  while 
it  less  is  removed  the  disease  may  be  imperfectly  removed  or  ankylosis  may 
recur. 

It  Beems  must  rational  to  remove  only  diseased  tissue,  and  this  as  far 
as  may  be  needed,  for  if  the  epiphyseal  line  be  badly  involved  its  preserva- 
tion will  not  be  much  good  to  the  patient.  When  the  condition  is  healed. 
if  it  be  found  after  some  months  that  movement  is  poor  and  a  movable 
joint  is  desirable,  the  joint,  if  quite  sound  as  regards  tubercle,  might  be 
reopened  and  a  strip  of  fascia  from  the  triceps  inserted  between  the  ends 
of  the  bones  to  prevent  ankylosis.  Early  movement  is  generally  advised 
in  these  eases  to  promote  freedom  from  adhesions;  this  seems  somewhat 
risky  in  tubercle  unless  removal  has  been  very  complete,  as  in  early  cases 
before  there  is  format  ion  of  sinuses. 

(d)  Ankylosis.  This  may  result  from  healed  tubercle  or  pyogenic  disease 
(including  gonorrhoea)  and  fractures  of  the  lower  end  of  the  humerus  into 
the  joint,  and  may  be  fibrous  or  bonv. 

Where  the  ankylosis  is  in  good  position,  i.e.  with  the  forearm  flexed 
to  just  beyond  a  right-angle,  the  question  of  operation  is  doubtful.  If 
the  patient  is  satisfied  with  the  arm  for  work  and  feeding  it  will  be  best 
left  alone. 

But  if  a  movable  joint  is  essential  to  his  well-being  an  arthroplasty 
should  be  carried  out,  i.e.  an  excision  with  removal  of  but  little  bone,  and 
the  interposition  of  a  flap  of  fascia  between  the  ends.  Where  the  ankylosis 
is  in  extension  there  need  be  no  hesitation  about  operating,  since  even  if 
there  be  failure  to  secure  a  mobile  joint  the  position  can  always  be  much 
improved  to  one  of  flexion.  It  is  often  taught  that  cases  of  ankylosis  in 
children  should  be  left  till  the  bones  have  done  growing  lest  damage  to  the 
epiphyses  interfere  with  this:  since,  however,  the  muscles  atrophy  all 
the  time  the  joint  remains  stiff,  the  outlook  for  a  functional  joint  after  many 
years  of  waiting  is  poor,  and  if  the  small  amount  of  bone  necessary  for  an 
arthroplasty  be  removed  there  will  be  no  need  to  interfere  with  the  epiphyseal 
line.  The  only  necessity  for  this  operation  is  that  the  joint  is  soundly 
healed,  as  any  Small  infective  locus  will  lead  to  failure.  After  these 
operations  the  joint  should  lie  put  up  in  the  flexed  position,  passive 
movements  of  the  lingers  commenced  in  three  days,  the  elbow  moved  after 

a    Week. 

(e)  Fhnl  Elbow.  In  these  cases  the  joint  is  loose  and  out  of  control, 
hyper-extension  being  often  present.  The  condition  results  from  excision 
sphere  too  much  bone  has  been  removed  or  in  paralyses  of  the  arm  from 
infantile  palsy  or  nerve-injuries. 

Treatment.     Tl Ibow  should  be  fixed  to  a  right  angle  by  excising  a 

large  diamond-shaped  piece  of  skin  from  the  antecubital  fossa  (Jones)  and 
suturing  so  thai  the  elbow  is  flexed,  imitating  tin-  right-angled  deformity  so 
well  known  after  extensive  burns  in  this  region. 


OPERATIONS  AT  THE  ELBOW  475 

(/)  Rheumatoid  affections  arc  not  uncommon  in  the  joint.     In  selected 

cases  operative  treatment  in  the  form  of  arthroplasty  may  be  useful. 

(g)  Olecranon  Bursitis.  A  chronic  inflammation  of  this  bursa  with 
effusion  and  melon-seed  bodies,  from  repeated  slight  injuries  is  found, 
especially  in  miners.  The  fluctuating,  chronic  swelling  with  soft  crepitus 
confined  to  the  point  of  the  elbow  is  characteristic.  Excision  of  the  bursa 
should  be  done. 

Acute  suppurative  bursitis  also  occurs  here,  needing  free  opening  and 
drainage.  The  infection  is  liable  to  spread  and  cause  cellulitis  of  the  arm 
and  forearm,  so  that  treatment  must  be  prompt  and  decided,  incisions  being 
free  and  irrigation  with  peroxide  of  hydrogen  and  lysol  baths  assiduous. 

Operations  at  the  Elbow.  (1)  The  joint  may  be  aspirated  or  opened 
for  drainage  on  either  side  of  the  olecranon — preferably  on  the  outer  side 
of  this  to  avoid  the  ulnar  nerve. 

(2)  Excision  of  the  Elbow.  This  has  already  been  discussed  under 
Tuberculosis  of  the  Joint  and  the  operation  by  posterior  longitudinal  incision 
described.  Kocher's  method  is  also  useful.  A  three-inch  incision  is  made 
along  the  external  intermuscular  septum  down  to  the  head  of  the  radius 
and  then  carried  obliquely  back  to  the  subcutaneous  border  of  the  ulna, 
which  is  reached  three  inches  below  the  tip  of  the  olecranon.  Through 
this  incision  the  triceps,  its  olecranon  insertion,  and  the  anconeus  are 
stripped  off  the  back  of  the  humerus  and  ulna  in  one  piece,  the  external 
ligaments  divided,  the  ends  of  the  bone  dislocated  through  the  wound, 
and  the  ends  of  the  bones  thus  exposed  are  dealt  with. 

(3)  Arthroplasty.  This  should  be  the  termination  of  the  operation  in 
cases  where  active  disease  is  no  longer  present,  a  flap  of  fascia  and  fat 

ver  the  triceps  being  turned-in  between  the  bones  after  they  have  been 
cut  away  sufficiently  to  permit  of  free  movement  of  the  joint.  The  joint  is 
put  up  at  a  right  angle  and  movements  commenced  within  the  first  week. 

(4)  Excision  of  the  Radio- ulnar  Joint,  or  Head  of  the  Radius.  This  is 
indicated  in  old-standing  cases  of  dislocation  of  the  radial  head  where 
flexion  of  the  elbow,  pronation,  and  supination  are  impaired  ;  also  for 
congenital  dislocation,  and  occasionally  in  severe  rheumatoid  arthritis 
confined  to  this  joint.  The  radial  head  may  be  reached  by  longitudinal 
incision  over  it  either  in  front  or  through  the  supinator  longus.  Care 
must  be  taken  not  to  injure  the  musculo-spiral  nerve  lying  to  the  inner  side 
of  the  head,  or  its  posterior  interosseous  branch,  which  crosses  the  neck 
of  the  radius  lower  down.  The  head  and  neck  as  far  as  the  tubercle  of  the 
biceps  should  be  removed,  and  if  movement  be  still  deficient  part  of  the 
capitelmm  as  well.  A  flap  of  fascia  should  be  inserted  to  prevent  osseous 
union  taking  place,  and  massage  and  movements  will  need  to  be  emplj 

for  a  long  while  before  function  is  restored. 

(5)  Amputation  or  Disarticulation  at  tin  Elbow-joint.  The  large  lower 
end  of  the  humerus  provides  a  convenient  support  for  an  artificial  limb. 
The  operation  may  be  done  by  circular,  modified  oval,  or  flap  methods. 
according  as  the  soft   parts   present   suitable   facilities.     The  skin  of  the 


\  TEXTBOOK  OF  SURGERY 

posterioi  surface  is  tougher  and  more  used  to  pressure,  and  hence  the  longer 
flap  01  lower  end  of  the  eclipse  should  be  behind.     A  convenienl  method  is 

to  make  a  circular  incision  '2\  in.  below  the  condyles,  dissecting  skin  ami 
fascia  to  the  joint  level,  which  is  then  disarticulated,  starting  most  conve- 
niently on  the  outer  side  at  the  radio-humeral  joint.  The  skin  is  sutured 
transversely.  Owing  to  the  greater  retraction  of  the  skin  of  the  anterior 
surface  the  cicatrix  will  lie  in  front  and  is  not  pressed  on  by  the  condyles. 
so  that  the  method  is  practically  by  a  posterior  flap  (Miller).  The 
brachial  artery  and  anastomotic  vessels  aboul  the  joint  will  need  ligatures, 
and  tin1  median,  musculo-spiral,  ulnar,  and  internal  cutaneous  nerves  are 
to  he  divided  high  up. 

The  Forearm.  ('/)  Deformities.  These  may  be  of  osseous  or  muscular 
ami  tendinous  origin. 

(1)  Bonn  Deformities,  (a)  Congenital.  The  most  usual  is  partial  or 
complete  absence  of  the  radius,  causing  the  hand  to  be  deflected  in  the 
radial  (abducted)  position  (club-hand)  and  resulting  in  considerable  weak- 

of  the  limb.  It  may  be  feasible  to  split  the  lower  end  of  the  ulna 
to  take  the  place  of  the  radius. 

(b)  Acquired  deformities  are  due  to  shortening  of  the  radius  either  from 
damage  to  the  lower  epiphysis  of  the  growing  bone,  whether  by  injuries  or 
inflammations.  As  a  result  its  growth  is  impaired  and  the  unaffected  ulna 
pushes  the  hand  round  into  the  abducted  position,  as  in  '*  club-hand." 

Where  there  is  much  disability  the  ulna  may  be  shortened,  the  position 
of  the  wrist  corrected  and  maintained  by  suitable  apparatus  controlling  the 
wrist. 

(2)  Deformities  due  to  muscular  affections  may  result  from  paralysis, 
spasm,  or  contracture  (the  latter  are  discussed  under  Affections  of  the 
Fingers). 

(a)  Anterior  poliomyelitis  does  not  commonly  affect  the  upper  limb 
but  may  cause  "dropped  wrist"  from  paralysis  of  the  extensors  of  the 
wrist  and  fingers.  The  paralysed  muscles  follow  the  general  rule  of  becoming 
stretched  if  allowed  to  do  so,  seldom  recovering  their  length  without 
an  operation  for  tendon-shortening.  Therefore,  in  such  cases  palmar 
flexion  of  the  wrist  and  fingers  should  be  prevented  by  splinting  the  wrist 
and  fingers  in  a  position  of  hyper-extension  and  using  massage  till  recovery 
is  well  developed. 

(h)  Spastic  contractures  follow  upper-segment  nervous  lesions  occasioned 
at  or  before  birth.  The  forearm  is  pronated,  the  wrist  and  fingers  flexed. 
The  condition  can  often  be  improved  by  the  use  of  massage  and  malleable 
splints,  which  are  gradually  altered  as  the  condition  improves.  If  progress 
on  these  lines  is  not  satisfactory  the  pronator  radii  teres  maybe  used  to 
reinforce  the  supinators,  being  detached  from  its  insertion,  passed  through 
the  interosseous  membrane,  and  again  sutured  in  its  place,  when  it  will 
ad  as  a  supinator;  or  some  of  the  flexor  tendons  may  be  made  to  serve 
rtensors  in  a  similar  manner.  Success  can  only  be  moderate  in  these 
cases. 


THE  WRIST  477 

Inflammations  and  Infections.  The  radius  and  ulna  may  be  affected 
with  acute  diaphysitis,  and  the  radius  is  one  of  the  long  bones  most  prone 
to  tuberculous  osteom)Telitis.  Gummata  are  found  especially  on  the  sub- 
cutaneous surface  of  the  ulna. 

(c)  New  Growths.  The  lower  end  of  the  radius  is  one  of  the  commonest 
places  for  the  appearance  of  myeloid  sarcoma.  Periosteal  sarcomas  are 
found  growing  from  either  bone,  and  it  is  questionable  whether  amputation 
of  the  limb  higher  up  is  justifiable  when  local  removal  gives  any  prospect 
of  temporary  success  with  preservation  of  a  useful  limb. 

The  skin  of  the  forearm  is  one  of  the  special  seats  of  epithelioma  caused 
by  irritation,  as  found  in  tar  and  paraffin  workers. 

Amputation  through  the  Forearm,  (a)  In  the  upper  part  anterior 
and  posterior  flaps  are  most  suitable.  Flaps  about  2h  in.  long  are  cut 
through  the  skin  and  fat  and  allowed  to  retract,  the  underlying  muscles 
being  cut  by  transfixion.  The  radial,  ulnar,  and  interosseous  vessels  will 
need  ligature,  and  the  median,  ulnar,  and  radial  nerves  must  be  dissected 
and  divided  high  up.  The  bones  are  sawn  through  together,  but  the  section 
of  the  less  stable  radius  should  be  completed  first. 

(b)  In  the  lower  part  of  the  forearm  the  circular  method  is  excellent. 
A  cylindrical  cuff  of  skin  and  fascia  about  2  in.  in  length  is  turned  back  : 
the  tendons  are  divided  most  readily  by  transfixion  ;  the  vessels  and  nerves 
are  divided  as  before. 

In  accident  cases  the  flaps  must  be  cut  as  the  situation  allows  ;  in  some 
instances  the  skin  of  part  of  the  hand  may  be  utilised.  The  stump  should 
be  as  long  as  possible  and  every  effort  should  be  made  to  divide  the  bones 
below  the  insertion  of  the  pronator  radii  teres,  or  the  useful  movements 
of  supination  and  pronation  will  be  lost. 

AFFECTIONS  OF  THE  WRIST 

(<t)  Congenital  dislocation  of  this  joint  is  described. 

(b)  Madelung's  Deformity.  This  is  found  in  young  women,  and  consists 
ina  subluxation  forward  of  the  lower  end  of  the  radius  from  the  ulna,  which 
projects  notably  backward.  The  radius  is  shorter  than  normal  and  curves 
forwards;  there  may  be  signs  of  rarefaction  of  the  lower  radius  (X-ray). 
To  a  less  degree  there  is  dislocation  of  the  carpus  forward  on  the  radius. 
The  onset  is  insidious,  and  it  appears  to  be  increased  by  occupations  in 
which  powerful  grasping  with  the  hand  is  needed  in  young  persons  whose 
epiphyses  are  ununited.  In  addition  to  the  characteristic  deformity  there  is 
loss  of  power  in  the  hand-grip.  The  causation  is  obscure  :  it  is  connected 
in  some  way  with  epiphyseal  growth  in  length  of  the  bone.  Rickets  has 
hern  called  in  question,  but  there  is  no  proof  of  its  being  a  cause.  The 
condition  is  one  of  subacute  inflammation  of  the  radius  of  unknown 
origin. 

Treatment.  The  joint  should  be  rested  and  massaged;  a  generous  diet 
and  tonics  are  beneficial.  The  deformity  ceases  to  develop  alter  twenty- 
five.     Operative  measures  are  not  advisable. 


178  A  TEXTBOOK  OF  SURGERY 

Inflammations.  Acute  gonorrhoea]  infection  is  not  uncommon;  less 
often  from  pyaemia,  infected  wounds,  or  gout. 

Osteo-arthritis  is  uncommon,  but  neuropathic  disease  due  to  syringo- 
myelia causes  a  characteristic  thickening  of  the  wrist,  giving  the  extremity, 
in  advanced  cases,  the  appearance  of  the  ]>a\\  of  one  of  the  feline  race. 

Tuberculosis  of  the  Wrist.  This  is  fairly  common  and  usually  starts 
in  the  synovial  membrane,  though  loci  may  be  noted  early  in  the  carpal 
hones  and  occasionally  in  the  lower  end  of  the  radius  or  metacarpal  bases. 

-.  The  onset  is  with  feeling  of  weakness  and  impaired  movement 
of  the  joint  and  diminished  power  of  the  grasp;  later  the  wrist  becomes 
the  seat  of  typical  white  swelling,  and  the  atrophic  muscles  of  the  forearm 
above  and  of  the  thenar  and  hypothenar  eminences  below  rende;  the  swelling 
more  obvious.  The  swelling  is  noted  especially  on  the  dorsum,  above  and 
below  the  posterior  annular  ligament  :  less  on  the  palmar  aspect  owing  to 
the  hulk  of  the  intervening  flexor  tendons,  (old  abscesses  come  to  the 
surface  on  the  dorsum  or  on  the  palmar  surface  above  the  annular  ligament. 

Diagnosis  is  made  from  gonorrhoea!  affection  by  the  greater  chronicity, 

and  later  by  abscess-formation  :    from  compoimd-palmar  ganglion  by  the 

obvious  palmar  swelling,  which  does  not  fluctuate  through  the  aperture 

of  the  anterior  annular  ligament,  and  by  the  presence  of  dorsal  swelling  and 

greater  impairment  of  movement  of  the  joint. 

Treatment.  The  joint  should  be  immobilized  in  a  poroplastic  splint 
reaching  from  the  elbow  to  the  metacarpal  heads,  which  keeps  the  joint  in 
slight  hyper-extension  and  allows  the  fingers  to  move;  these,  however, 
should  not  be  allowed  to  do  any  work,  even  the  lightest.  Cold  abscesses 
are  aspirated  if  they  increase  and  sinuses  curetted  and  filled  with  bismuth- 
paste.  In  young  persons  excision  of  the  joint  is  worth  a  trial  where  the 
disease  is  advancing  in  spite  of  all  care.  In  middle-aged  or  elderly  persons 
it  is  almost  certain  to  fail  and  amputation  is  generally  needed. 

Excision  of  the  Wrist.  The  joint  may  be  exposed  by  a  dorsal  or 
ulnar  incision,  which  may  be  used  separately  or  together.  The  dorsal 
incision  lies  between  the  tendon  of  the  extensor  communis  and  that  of  the 
secundi  internodii  pollicis,  and  is  about  four  inches  long,  the  middle  being 
over  the  carpus.  The  ulnar  incision  extends  down  the  lower  inch  or  two 
of  the  ulna  to  the  base  of  the  fifth  metacarpal ;  this  may  be  longer  or  shorter 
according  to  necessity.  The  tendons  are  carefully  stripped  oft'  the  carpal 
bones,  only  the  radial  carpal  extensors  being  divided;  the  radio-carpal 
joint  is  opened  and  the  carpal  bones  extracted  singly,  dividing  their  con- 
nections as  most  convenient.  The  trapezium  is  left,  if  possible,  to  afford 
support  to  the  thumb,  and  the  hook  of  the  unciform  with  the  pisiform 
i-  also  left  with  the  insertion  of  the  flexor  carpi  ulnaris.  The  lower  ends 
of  the  radius  and  ulnar  are  examined  and  diseased  portions  removed  with 
gouge  ,„  BaWj  ;i||(j  t|l(.  ba8es  of  the  metacarpals  treated  in  similar  manner. 
All  diseased  synovial  membrane  and  tendon-sheaths  are  dissected  away. 
I  he  wound  is  drained  for  two  days  and  put  up  in  extension  ;  finger  move- 
mentsare  practised  from  the  m-st    movements  of  the  wrist  after  three  weeks, 


AMPUTATION  AT  THE  WRIST 


470 


commencing  very  gently.     Movements  must  be  practised  for  several  months 
if  a  useful  hand  is  to  be  the  result. 

Amputation  at  the  Wrist.  This  will  seldom  be  needed,  as  if  any 
part  of  the  hand,  especially  of  the  thumb,  can  be  preserved  it  will  well  repay 
the  trouble.  Flaps  are  taken  from  what  skin  is  left,  preferably  from  the 
palmar  surface,  whether  as  a  long  palmar  flap  extending  down  to  the  necks 
of  the  metacarpals  or  as  an  elliptical  section  with  the  lower  part  opposite 
their  bases.  In  any  case  the  anterior  part  or  flap  should  include  all  struc- 
tures down  to  the  tendons  to  ensure  a  good  blood-supply,  and  will  include 
portions  of  the  thenar  and  hypothenar  muscles.      The  styloid  processes 


Excessive  ili-it-  1 1  < . I j- t »  r  claw  deformity). 


are  usually  left,  but  may  be  removed  if  the  flaps  are  short.  Where  the 
wrist-joint  is  involved  in  disease  the  amputation  will  generally  be  above 
the  wrist. 

THE  HAND  AND  FINGERS 

The  hand  and  fingers  are  placed  in  close  connexion  by  means  of  the 
tendons  and  their  sheaths,  and  the  surgery  of  the  part  is  very  largely  that 
of  the  tendons. 

(a)  Deformities  may  be  congenital  or  acquired. 

(1)  Congenital  Deformities,  (a)  The  fingers  may  be  abnormal  in 
size  or  numbers.  Thus  local  gigantism  of  one  or  more  fingers  (macro- 
dactyly)  may  render  the  hand  clumsy  and  awkward,  ami  tin-  offending  digit 
should  be  resected.  There  may  be  excess  of  lingers  to  the  number  of  six 
to  twelve  in  all.  some  of  the  accessory  fingers  being  useless  and  flail-like. 
In  some  cases  the  end  of  a  metacarpal  may  be  split  and  well-developed 
fingers  originate  from  either  branch  (lobster-claw  deformity).  The  mal- 
formations are  hereditary. 


A  TEXTBOOK  OF  SURGERY 

Treatment.  The  useless  digits  are  removed  unless  serving  as  a  means 
of  livelihood. 

(/»)  Webbed  Fingers.  The  digits  are  connected  by  a  membrane  to  a 
greater  or  less  extent  of  their  length;  the  connecting  link  may  be  thin 
and  membranous  or  dense  and  of  nearly  the  same  thickness  as  the  angers. 

Treatment.  Operations  should  be  done  in  childhood,  bul  not  before 
four  vears  of  age  on  account  of  the  difficulty  in  operating  on  small  fingers. 
If  the  web  is  simply  divided  it  will  surely  cicatrize  and  recur  from  the 
junction  of  the  fingers.  Consequently  a  triangular  flap  should  be  turned 
up  and  inserted  between  the  digits  in  the  slit  thus  made.  The  flap  must 
be  long,  the  base  being  at  the  metacarpal  neck,  the  apex  at  the  middle  of 
the  second  phalanx.  Having  raised  such  a  flap  from  the  dorsal  surface, 
the  rest  of  the  web  is  split  down  to  the  metacarpal  head  and  the  flap  sewn 
into  the  gap  to  prevent  cicatricial  union  at  this  point.  The  bared  side  of  the 
digits  will  epithelialize  from  the  sides  of  the  -wound. 

(c)  Congenital  contraction  of  the  palmar  fascia  of  the  second  and  third 
phalanges,  causing  these  to  be  flexed,  is  readily  distinguished  from  Dupuy- 
tren's  acquired  contracture,  wrhere  the  first  phalanx  is  flexed,  the  second 
and  third  extended.  (Fig.  19-1,  V.) 

Trmf mi  nt.  Careful  splinting  in  an  extended  position  after  dividing  the 
contracted  bands  of  fascia  will  effect  a  cure. 

(2)  Acquired  Deformities.  These  may  be  of  nervous,  muscular,  tendi- 
nous, fascial,  or  bony  origin. 

(a)  Nervous.  The  defective  movement  and  deformity  due  to  injuries 
of  the  median  and  ulnar  nerves,  the  inner  cord  of  the  plexus,  &c,  is  described 
in  the  section  on  Nerve  Injuries  ;  the  effect  of  nervous  lesions  of  the  upper 
segment  have  been  mentioned  under  Affections  of  the  Forearm. 

(b)  Ischsemic  contracture  of  the  forearm  muscles  (Volkmann)  is  described 
under  Injuries  of  Muscles  (p.  255) :  suffice  it  here  to  note  that  not  only  are  the 
flexors  of  the  fingers  contracted  but  those  of  the  wrist  as  well,  so  that  if 
the  wrist  be  hyperflexed  the  fingers  can  be  extended  to  some  degree  ;  also 
that  t  he  pronator  radii  teres  is  affected,  leading  to  pronation  of  the  forearm 
in  addition  to  flexion  of  the  wrist  and  fingers.   (Fig.  195,  III,  IV.) 

(c)  Deformities  from  affections  of  tendons  may  result  from  their  rupture 
or  division  or  from  their  becoming  adherent  in  their  sheaths  or  destroyed 
by  infections.  The  flexor  tendons  are  more  often  ruptured  or  divided, 
with  the  result  that  active  flexion  is  destroyed  though  passive  flexion  is  still 
possible.  The  loss  of  power  on  voluntary  movement  or  electrical  stimulus 
will  decide  which  tendons  are  affected.  Where  there  is  no  wound  it  may 
be  impossible  to  say  where  the  tendon  has  been  ruptured  ;  as,  however,  they 
more  often  L'ive  away  either  at  their  muscular  or  bony  attachments  than 
in  the  middle  of  their  length,  it  will  lie  best  to  explore  the  two  ends  first 
in  attempting  tendon-suture. 

Adhesions  of  tendons  in  their  sheaths  is  a  common  cause  of  deformity 
and  usually  follows  on  pyogenic  infection,  the  tendon  being  merely  adherent, 
or  destroyed  to  a  varying  extent.     The  deformity  will  vary  with  the  position 


TRIGGER-FINGER 


481 


maintained  while  healing  took  place,  the  finger  being  rigid  in  extension  or 
flexion.  On  attempting  movements  (in  the  case  of  the  flexor  tendons, 
which  are  most  usually  affected)  there  will  be  no  tightening  of  fascial  bands 
in  the  palm  (as  in  Dupuytren's  contracture),  or  of  the  tendons  above  the 
wrist  (as  in  ischsemic  contracture) ;  nor  will  forced  flexion  of  the  wrist  increase 
the  range  of  movement,  as  in  the  latter  condition.  Very  often  the  joints 
in  these  cases  are  ankylosed  as  well. 

Treatment.     Passive  movements,  hot-air  baths,  and  injection  of  fibre* 
lysin  may  improve  the  less  aggravated  cases ;    but  in  severe  cases  where 


^ 


^^ 


u 

Fig.  195.  Diagrammatic  sections  of  deformities  of  the  hand.  I,  Ulnar  paralysis  ; 
flexion  of  the  distal  phalanges  by  the  long  plexus  ;  extension  of  the  first  phalanx  by 
the  extensor  digitorum  (interossei,  out  of  action).  II.  Contraction  of  the  palmar 
fascia  (Dupuytren).  Ill,  Ischaemic  contraction  of  the  flexors  of  the  wrist  and  fingers 
(Volkmann).  IV,  Hyperflexion  at  the  wrist  enables  the  fingers  to  be  extended. 
V,  Contraction  of  the  digital  fascia  (congenital). 


T 


there  has  been  much  sloughing  and  the  circulation  of  the  part  is  bad,  no 
treatment  is  likely  to  give  much  improvement.  Freeing  the  tendons  and 
surrounding  them  with  Cargile  membrane  to  prevent  further  adhesions  is 
likely  to  prove  disappointing  but  is  worth  a  trial  in  young  subjects,  as 
otherwise  amputation  of  digits,  that  are  in  the  way,  is  all  that  can  be  done. 

(d)  Another  condition  due  to  affection  of  tendons  is  that  of  "  snap  "  or 
"  trigger  "  finger.  The  finger  or  thumb  can  be  flexed  by  the  patient  with 
some  difficulty,  but  cannot  be  extended  by  the  weaker  extensor  muscles. 
Should  a  more  powerful  contraction  of  the  latter  or  assistance  from  the 
other  hand  enable  extension  to  be  made,  the  joint  extends  with  a  sudden 
snap  like  that  of  a  trigger  or  a  clasp-knife.  The  condition  is  due  to  the 
presence  of  a  local  enlargement  of  the  tendon,  too  large  to  pass  readily  down 
the  tendon-sheath — which,  however,  if  sufficient  force  be  used,  will  finally 
1  3i 


A  TEXTBOOK  OF  SURGERY 

pass  the  obstruction  with  a  jerk.  The  enlargement  <>f  the  tendon  may 
be  duo  to  inflammatory  thickening,  or  there  may  be  a  small  ganglion-like 
structure  formed  in  the  tendon. 

Treatmt  nt.  Massage  and  movemenl  may  diminish  the  size  of  the  tendon  : 
failing  this,  the  pari  should  be  explored  and  the  tendon-sheath  slit  up  to 
permit  of  passage  of  the  enlarged  tendon,  or  if  a  well-localized  lump  be 
found  on  the  tendon  this  may  be  excised.  Movements  should  be  com- 
menced as  soon  as  possible  to  prevent  adhesions  of  the  tendon  in  its  sheath. 

"Mallet  "  and  '"  baseball"  finger,  due  to  rupture  of  the  extensor  and 
flexor  tendons  near  their  insertion,  are  described  in  the  section  on  Rupture 
of  Tendons  of  the  Fingers. 

(e)  Fascial  Deformity.  Dupuytren's  contracture  of  the  palmar  fascia 
is  of  unknown  origin  and  is  found  in  middle-aged  persons.  The  condition 
is  probablv  due  to  an  irritant  of  some  sort.  There  may  be  a  history  of 
pressure  of  some  implement  frequently  used,  such  as  spade,  walking-stick, 
fee.,  but  there  is  often  no  reason  of  the  kind.  Gout,  "  nervous  influence," 
and  even  a  specific  germ  have  been  invoked  as  causes,  but  on  no  very  well- 
assured  basis.  The  fact  that  the  fibrosis  starts  in  the  superficial  layers  of 
the  fascia  next  the  skin  and  passes  inwards  suggests  irritation  coming  from 
the  surface,  but  whether  infective  or  from  repeated  trauma  is  uncertain. 
The  affection  starts  as  a  subcutaneous  nodule  at  the  junction  of  the  skin 
and  deep  fascia  on  the  palmar  surface  of  the  third  and  fourth  metacarpals. 
The  fascia  is  gradually  invaded  and,  being  invaded,  becomes  a  fibrous  cord 
which  contracts,  causing  flexion  of  the  third  and  fourth  fingers  at  their 
mt'tacarpo-phalangeal  joints,  the  remaining  phalanges  remaining  extended  ; 
finallv  the  fingers  are  bent  right  into  the  palm,  greatly  interfering  with  the 
use  of  the  hand. 

Diagnosis.  This  affection  is  distinguished  from  contraction  of  a  tendon 
by  the  involvement  of  the  skin  and  by  the  fact  that  on  attempting  extension 
there  is  no  tightened  cord  felt  above  the  wrist ;  also  the  flexion  of  the  first 
phalanx  only,  is  characteristic  of  this  condition,  and  the  contracted  fascia 
can  often  be  felt  splitting  into  its  two  divisions,  going  to  the  sides  of  the 
first  phalanx  :  these  points,  as  well  as  the  age  of  the  patient,  will  distinguish 
Dupuytren's  contracture  from  the  congenital  form,  which  is  usually  seen 
in  children. 

Treatment.  Temporary  relief  may  be  obtained  by  wrearing  a  dorsal 
splint  at  night  to  prevent  flexion,  avoiding  pressure  on  the  palm  and  the 
use  of  massage,  movements,  and  injection  of  fibrolysin.  The  condition 
usually  progresses  in  spite  of  such  treatment,  and  since  mere  division  of 
fascia  is  only  followed  by  further  contraction  it  will  be  necessary  to  excise 
the  fascia  widely.  This  is  done  by  a  V-incision  over  the  contracted  fascia 
with  the  angle  of  the  V  proximal.  This  flap  is  dissected  up  from  the  fascia, 
which  is  cleared  off  the  deeper  structures  with  a  good  margin  of  healthy 
te  ;  the  flap  is  sutured  in  place,  and  as  the  finger  is  extended  will  assume 
the  form  of  a  Y.  A  dorsal  splint  should  be  worn  at  night  for  at  least  a 
year  to  prevent  flexion,  and  movements  practised  after  a  wreek. 


WHITLOW.     PARONYCHIA  483 

(/)  Deformities  of  bon)r  origin  demand  but  brief  notice.  The  ulnar 
deviation  of  ringers  and  nodes  of  Heberden  found  in  rheumatoid  arthritis 
are  of  this  nature,  and  the  dropping  back  of  the  knuckles  from  fractures 
of  the  metacarpal  bones  may  be  mentioned. 

(3)  Infections  of  the  Hand  and  Fingers.  Acute  infections  with 
the  pyogenic  cocci  are  chiefly  to  be  considered,  but  the  reader  must  under- 
stand that  the  hand  and  fingers,  as  tactile  and  exploring  organs,  are  liable 
to  all  manner  of  infections,  such  as  syphilis  from  examining  patients,  tetanus 
from  gardening,  glanders,  diphtheria,  tubercle,  &c. 

These  infections  are  inoculated  into  minor  injuries  such  as  scratches, 
pricks,  tearing  of  the  paronychial  skin,  and  the  surgeon  will  do  well  to 
remember  that  the  less  he  touches  possible  infective  material  with  ungloved 
hands  the  better  for  his  future  patients  and  himself. 

(a)  Acute  infections  (whitlow)  of  the  hands  and  fingers  are  of  various 
sorts,  and  often  take  place  in  abrasions  and  tears  at  the  root  of  the  nail, 
resulting  from  pricks  with  needles  or  thorns,  or  from  infection  of  hair 
follicles  on  the  back  of  the  hand  or  fingers.  The  infection  may  spread  to 
the  subcutaneous  tissues  or  even  to  the  tendons  and  bone.  Anatomically 
we  may  distinguish  superficial  infection,  which  in  the  region  of  the  nail  is 
called  paronychia,  thecal  suppuration  when  the  tendon-sheaths  are  affected, 
and  osteitis  where  the  infection  has  reached  the  bone. 

Paronychia.  This  starts  at  the  side  of  the  nail  as  a  painful  red 
swelling,  which  under  suitable  treatment  may  subside  and  remain  super- 
ficial, but  may  spread  under  the  nail  into  the  nail-bed  as  deep  paronychia. 
Infection  of  the  nail-bed  may  occur  directly  also,  as  by  running  an  infected 
thorn,  needle,  or  splinter  into  the  pulp  of  the  finger  between  the  nail  and 
the  bone.  The  inflamed  tissues,  being  confined  between  the  rigid  nail  and 
the  bone,  cannot  expand  readily  and  cause  extreme  pain  of  a  throbbing 
nature.  There  is  general  swelling  of  the  end  of  the  digit,  which  becomes 
red  and  later  purple,  while  a  white  or  yellow  discoloration  will  be  seen  beneath 
the  nail  from  the  presence  of  pus  in  this  situation.  The  fever  and  general 
malaise  are  marked,  considering  the  smallness  of  the  local  lesion.  The 
inflammation  gradually  and  painfully  spreads  in  the  nail-bed,  the  nail 
becoming  detached  ;  possibly  the  bone  is  invaded  and  necrosis  of  part  or 
all  of  the  terminal  phalanx  takes  place,  in  such  cases  the  end  of  the  digit 
being  swollen  to  twice  or  thrice  its  normal  size  and  cedematous  and  dis- 
coloured  with  oozing  sinuses  about  the  nail.  Spread  may  proceed  into 
the  tendon-sheath  and  thecal  whitlow  result.  After  a  few  weeks  the  necrosed 
phalanx  will  separate,  and  healing,  with  deformity  of  the  terminal  phalanx, 
take  place. 

Treatment.  Early  and  energetic  measures  are  needed  and  may  save 
some  of  the  above-mentioned  results  of  infection.  In  the  slighter  cases 
where  the  infection  is  superficial,  i.e.  still  above  the  bed  of  the  nail,  the 
inflammatory  swelling  should  be  incised  and  fomented,  when  it  may  subside. 
If,  however,  it  begins  to  spread  under  the  nail,  it  will  be  necessary  to  remove 
some  or  all  of  this  to  allow  of  free  drainage.     Occasionally  this  may  be 


18-J  \  TEXTBOOK  OF  SURGERY 

managed,  if  the  infection  is  to  one  Bide,  by  cutting  the  nail  well  hack,  but 
in  most  instances  it  will  be  necessary  to  remo^  e  the  whole  nail  (under  nitrous 
oxide  ansBsthesia,  necrosis  forceps  are  forced  well  back  under  the  nail  and 
the  latter  twisted  from  its  bed).  There  should  be  no  hesitation  in  removing 
the  nail  early  in  cases  where  infection  is  clearly  spreading  underneath  it, 
as  drainage  otherwise  is  impossible,  while  removal  of  the  nail  will  allow 
good  drainage  and  relieve  the  patient  of  much  pain  as  well  as  prevent  the 
spread  of  infection  to  deepei  structures,  such  as  the  bone  and  tendon- 
sheath.  Alter  the  nail  is  removed  or  cut  back  the  infected  area  is  freely 
opened  and  fomentations,  lysol  baths,  and  irrigation  with  peroxide  of 
hydrogen  (ten  volumes)  freely  used.  The  nail  will  grow  again  in  two  or 
three  months,  allowing  ample  time  for  the  infection  to  heal,  and  if  removed 
early  before  the  nail-be  1  is  much  injured  by  infection  will  not  be  deformed. 

Onychia  Maligna  is  a  similar  condition  occurring  in  ill-nourished  children, 
who  are  often  the  subjects  of  congenital  syphilis.  Treatment  is  on  similar 
lines,  but  tonic  or  specific  treatment  is  advisable  as  well  as  local.  In  these 
cases  the  condition  is  less  painful,  the  nail  separating  quietly  and  being 
surrounded  with  much  oedema  and  granulation-tissue. 

Subcuticular  Whitlow.  In  these  cases  the  infection  is  quite  superficial, 
being  just  below  the  epidermis,  which  is  raised  in  purulent  blebs.  Removal 
of  the  skin  over  these  latter  and  fomentations  will  result  in  rapid  cure. 

Simple  Whitlow.  In  other  examples,  again,  the  suppuration  is  in  the 
pulp  of  the  front  of  the  digit,  occurring  as  a  cellulitis  of  the  pulp,  going  on 
to  abscess-formation,  which  will  need  opening  on  the  palmar  aspect  of  the 
finger.  These  are  less  usual  than  the  former  types,  though  in  the  earlier 
stages  it  may  not  be  easy  to  locate  the  exact  position  of  the  infective  focus 
owing  to  the  general  swelling  and  oedema.  Such  simple  whitlows  may  lead 
to  necrosis  of  the  terminal  phalanx  or  thecal  whitlow. 

Thecal  Whitlow.  This  may  follow  from  paronychia  or  simple  whitlow. 
or  result  from  an  infected  wound  of  the  tendon-sheath.  The  finger  becomes 
red,  tender,  swollen,  and  cedematous  as  before,  but  the  swelling  extends 
to  the  root  of  the  finger  and  movements  of  the  latter  are  painful  and  much 
impaired — which  will  distinguish  this  condition  from  other  whitlows  where 
t  Inre  may  be  oedema  of  a  large  part  of  the  digit.  In  the  case  of  the  thumb 
ami  little  finger  the  swelling  and  redness  may  pass  along  the  tendon-sheaths 
to  the  palm  and  wrist ;  such  a  spreading  may  also  happen  in  the  other  fingers, 
t  he  infection  travelling  in  the  palm  as  a  cellulitis  and  not  as  a  thecal  infection. 
The  spread  may  be  very  wide,  involving  the  palmar-sheath,  wrist- joint, 
and  carpal-bones,  causing  cellulitis  of  the  forearm,  or  even  spreading  gan- 
grene may  result  in  bad  subjects.  Even  in  the  slighter  cases  there  is  a 
considerable  chance  that  the  affected  tendons  will  slough. 

Treatment.  Passive  congestion  by  Bier's  method  is  commended  by 
some  writers,  but  we  have  seen  no  benefit  from  its  use  in  these  cases,  and 
it  may  lead  to  waste  of  valuable  time.  Early  and  free  incision  is  the  best 
method  of  dealing  with  thecal  whitlows,  thus  promoting  free  escape  of 
infective  material  and  exudation  of  bactericidal  bodies  from  the  blood- 


VAKIETIES  OF  WHITLOW  485 

stream,  especially  if  accompanied  by  the  use  of  baths  aud  irrigation.  Early 
incision  will  help  to  prevent  spread  to  the  palm  and  wrist  and  may  save 
the  tendons.  The  incisions  should  be  free  and  drain-tubes  are  not  advisable 
as  tending  to  cause  sloughing,  which  readily  takes  place  in  the  digital  tissues, 
especially  the  tendons.  The  incisions  should  be  made  in  the  mid-line  in 
the  fingers  (or  over  the  greatest  swelling  in  doubtful  cases  where  it  is  not 
absolutely  certain  if  the  theca  is  infected).  In  the  palm  incision  should 
be  over  the  metacarpal  bones  to  avoid  the  vessels  and  nerves  and  distal  to 
the  junction  of  the  web  of  the  thumb  with  the  palm  to  avoid  injury  to  the 
superficial  palmar  arch.  Where  the  infection  has  spread  in  the  thecal  sheath 
above  the  wrist  the  incision  should  be  in  the  mid-line,  avoiding  the  median 
nerve  which  lies  between  the  palmaris  longus  and  flexor  carpi  radialis  tendons. 
Free  use  of  lysol  baths  and  early  passive  movements  to  prevent  adhesions 
end  promote  flow  of  antibacterial  lymph  should  be  commenced  as  soon  as 
possible.  In  hospital  practice  patients  often  come  up  too  late  and  the 
tendons  have  already  sloughed  or  become  so  adherent  that  when  healed 
the  hand  resembles  a  whale's  flapper.  But  where  operation  is  per- 
formed early  and  passive  movements  persevered  with,  good  use  of  the 
part  may  be  attained  even  after  widespread  suppuration  in  the  tendon- 
sheaths. 

Subperiosteal  Whitloiv  (Digital  Osteitis).  This  usually  follows  as  a 
complication  of  one  of  the  other  forms  of  whitlow — most  commonly  affecting 
the  terminal  phalanx,  occasionally  the  others.  The  condition  resembles 
the  other  varieties  in  the  earlier  stages  ;  later  the  huge  cedematous  swelling, 
the  purple  colour  of  the  digit,  as  well  as  sinuses  leading  down  to  bare  bone, 
will  make  the  diagnosis  clear. 

Treatment.  The  sequestrum  should  be  removed,  and  shortening  or 
stiffness  may  result.  In  the  former  case  the  finger  may  be  useful ;  in  the 
latter,  if  in  the  way,  it  is  best  amputated  when  healed. 

Complications  of  Whitlow.  Acute  Lymphangitis.  This  is  seen  as  a 
thin  red,  tender  line  along  the  course  of  the  lymphatics,  and  shows  the 
need  for  immediate  attack  on  the  infective  focus,  after  which  the  lymphan- 
gitis usually  clears  up  rapidly,  but  lymphadenitis  may  follow. 

Lymphadenitis  is  common  and  may  become  suppurative,  with  abscess- 
formation.  Such  a  termination  is  uncommon  in  the  epitrochlear  or  ante- 
cubital  glands,  but  is  not  uncommon  in  those  of  the  axillary,  where  exami- 
nation should  be  made  for  abscesses  and  these  opened  as  may  become 
necessary.  Another  place  where  suppurative  lymphadenitis  may  take 
place  is  the  space  between  the  pectoralis  major  and  the  deltoid,  where  the 
cephalic  vein  passes  through.  There  are  a  few  glands  here,  into  which 
drain  lymphatics  from  the  radial  border  of  the  arm  and  the  thumb  : 
suppuration  here  may  follow  infection  of  the  thumb,  so  that  it  is  important 
"to  recollect  this  collection  of  glands,  or  errors  in  diagnosis  may  result.  Spread- 
ing, infective  gangrene  may  occur  in  debilitated  subjects,  e.g.  alcoholics, 
or  where  the  infection  is  virulent ;  a  more  usual  condition  is  localized 
gangrene  of  the  digits  from  thrombosis  of  their  vessels. 


186  A  TEXTBOOK  OF  SURGERY 

Tuberculosis  <>k  the  Hand  and  Fingers.  Just  as  with  acute  infec- 
tions, so  with  tubercle  the  skin,  tendons,  or  bone  may  be  affected. 

The  skin  may  be  affected  by  lupus  vulgaris  or  anatomical  tubercle. 

Anatomical  Tubercle  or  Butcher's  Wart.  This  may  be  regarded  as  a  sort 
of  hypertrophic  lupus  occurring  in  butchers  or  slaughterers  from  infection 
with  tuberculous  meat,  and  is  more  rarely  in  these  days  found  in  pathologists. 
The  lesion  consists  of  a  warty,  chronically  inflamed,  and  infiltrated  condition 
of  the  back  of  the  knuckles  without  any  tendency  to  ulceration,  though  in 
some  instances  cordlike  thickening  of  the  lymphatics  may  be  traced  from 
the  lesion  along  the  arm  to  a  mass  of  easeating  glands  in  the  axilla. 

Treatment.  Where  local,  the  usual  constitutional  treatment  for  tuber- 
culosis and,  locally,  application  of  strong  nitrate  of  mercury  ointment,  or 
excision  of  the  mass  followed  by  skin-grafting  if  extensive  and  excision  of 
axillary  glands  if  enlarged. 

Tuberculous  Tenosynovitis.  This  occurs  as  a  painless  chronic  effusion, 
usually  into  the  flexor  tendon-sheaths,  associated  with  production  of 
granulation-tissue  and  perhaps  the  formation  of  melon-seed  bodies.  The 
condition  may  be  confined  to  one  finger,  or  if  the  thumb  or  little  finger  be 
affected  will  spread  to  the  great  flexor  sheath  in  the  palm  and  wrist,  when 
it  becomes  a  form  of  "  compound  palmar  ganglion." 

Signs.  There  will  be  found  considerable  loss  of  movement  and  painless 
effusion  in  the  sheath  :  where  the  palmar  sheath  is  affected,  the  swelling 
there  and  above  the  wrist,  with  fluctuation  between  the  two,  will  show  the 
presence  of  compound  palmar  ganglion.  The  tendon  sheaths  at  the  back 
of  the  wrist  are  also  affected  in  this  way,  especially  those  of  the  extensors 
of  the  thumb. 

Treatment.  Rest  on  a  splint  with  pressure  by  strapping  over  Scott's 
dressing  may  cure  the  less  severe  cases  ;  if  the  condition  advances  the 
sheath  should  be  opened,  the  effusion  evacuated,  all  granulation-tissue 
dissected  away,  and  the  wound  carefully  closed. 

Tuberculosis  of  the  Bones  of  the  Fingers  and  Hands  (tuberculous  dactyl- 
itis). This  is  common  in  children,  usually  under  five.  The  disease  starts 
as  a  chronic,  rarefying  osteitis  of  the  phalanges  or  metacarpal  bones,  one 
or  more  being  involved.  The  affected  part  swells  in  its  whole  circumference, 
though  in  the  case  of  a  metacarpal  bone  the  swelling  is  most  easily  noted 
on  the  dorsum  ;  later,  fluctuation  will  be  found  and  the  skin  becomes  red 
and  gives  way,  a  tuberculous  sinus  resulting.  In  the  earlier  cases  radio- 
graphs will  show  caries  and  necrosis,  with  stripping  of  the  periosteum  and 
some  formation  of  new  periosteal  bone. 

Treatment.  In  the  early  stages  keeping  the  part  at  rest  on  splints  or 
in  plaster,  administering  cod-liver  oil,  iron,  and  especially  mercury  in 
tin-  form  of  grey  powder  may  result  in  healing  before  sinuses  form.  Where, 
however,  abscess-formation  has  definitely  occurred  the  bone  should  be 
explored  by  an  incision  on  one  side  of  the  extensor  tendon,  the  abscess 
swabbed  out.  carious  and  necrosed  bone  removed,  and  the  wound  sutured  : 
where  sinuses  are  present  or  result  after  operation  they  should  be  scraped 


NEW  GROWTHS  OF  HAND  AND  FINGERS 


487 


out  and  filled  with  bismuth  paste.  Healing  usually  results  at  length, 
though  it  may  take  many  months  or  years  ;  and  the  fingers,  though  stunted, 
are  often  very  useful.  For  this  reason  amputation  should  be  avoided  as 
long  as  possible,  though  where  spread  of  the  infection  is  rapid  and  the 
digits  badly  disorganized  this  step  may  be  necessary. 

New  Geowths  of  the  Hand  and  Fingers.  Many  varieties  are  found, 
but  few  are  common. 

The  digits  and  metacarpals  are  the  places  of  election  for  growth  of 
multiple  chondromas,  which  may  be  known  as  chronic,  painless,  knobby 
tumours  in  young  persons  firmly  fastened 
to  the  bones  which  radiographic  examin- 
ation shows  them  to  be  invading. 

Melanotic  sarcomas  are  found  origin- 
ating in  the  nail-pulp  as  small  growths 
recognized  by  their  dark  colour  ;  en- 
largement of  the  axillary  glands  will  be 
found  early  and  microscopic  examina- 
tion will  show  their  nature  if  doubtful. 

Treatment.  The  digit  should  be  re- 
moved entire  with  metacarpal  bone,  and 
the  axillary  glands  excised  :  prognosis  is 
poor,  for  later  recurrences  in  viscera  are 
usual. 

Epithelioma  is  the  commonest  malig- 
nant tumour  and  may  grow  in  scars, 
especially  those  resulting  from  healed 
lupus,  also  from  trade  irritations  such  as 
tar,  paraffin,  X-rays,  &c. — though  the 
last  form  is  becoming  rare  owing  to  more 
adequate  protection  of  X-ray  operators. 

Warts  are  common :  excision  or 
application  of  solid  carbon  dioxide 
(for  forty  to  sixty  seconds)  will  readily  cure.  Implantation  cysts  from 
a  forcing  of  portions  of  the  epidermis  into  the  tissues  by  needle-pricks,  &c, 
occur  most  often  in  the  fingers ;  these  may  become  of  some  size,  and  if 
troublesome  may  be  removed. 

Amputation  of  the  Hand  and  Fingers.  These  operations  should 
always  be  approached  in  a  conservative  spirit,  particularly  in  cases  of  injury, 
and  above  all  when  the  thumb  is  in  question.  The  latter  should  never  be 
sacrificed  more  than  is  absolutely  necessary,  since  the  smallest  piece  of 
metacarpal  here,  still  more  of  phalanges  of  the  thumb,  vastly  improves 
the  grasp  of  the  hand.  In  amputating  fingers  the  last  phalanx  may  be 
removed  or  the  section  made  through  the  second ;  the  first  should  not  be 
saved  unless  the  flexor  tendons  are  firmly  sutured  to  the  end  of  the  stump, 
or  the  unopposed  extensors  will  make  the  stump  project  and  get  in  the  way. 
while  its  power  of  flexion  will  be  slight. 


Fig.  196.     Tuberculous  dactylitis. 
(Mr.  A.  J.  "Walton's  case) 


t88 


A  TEXTI'.ooK  <>F  SITRGERY 


The  terminal  phalanx  may  be  removed  by  a  palmar  flap  extending  from 
trie  joint  to  the  end  of  the  ringer,  the  joint  being  opened  by  a  dorsal  incision  in 
such  a  position  that  if  prolonged  it  would  split  the  end  of  the  second  phalanx. 
The  insertion  of  the  long  flexor  tendon  may  be  cut  from  the  palmar  surface. 

With  care  the  base  of  the  last  phalanx  may  be  spared  in  some  cases,  and 
tin-  should  be  done  if  possible  as  it  much  improves  the  power  of  flexion  of  the 

digit.  Amputation  through  the  second 
phalanx  may  be  done  by  long  palmar 
and  short  dorsal  flaps,  the  flexor-tendon 
being  sutured  to  the  end  of  the  stump. 
Amputation  through,  the  meta- 
carpophalangeal joint  is  done  by  a 
racket  incision,  which  starts  at  the 
neck  of  the  metacarpal  bone  and  is 
carried  down  to  the  level  of  the  web 
and  then  circularly  around  the  digit. 
The  soft  parts  are  peeled  off  the 
bone  and  the  joint  opened  from  the 
dorsum,  remembering  that  this  lies 
half  an  inch  above  the  web  and  im- 
mediately in  front  of  the  metacarpal 
head  when  the  joint  is  flexed  :  the 
flexor  tendons  are  cut  from  the 
palmar  surface.  The  head  of  the 
metacarpal  should  be  preserved  in  all 
those  who  need  their  hands  to  earn 
their  daily  bread,  but  if  appearances 
only  are  to  be  considered  it  may  be 
removed  at  its  neck.  The  wound  is 
sutured  in  an  antero-posterior  direc- 
tion. In  performing  this  amputation 
in  the  thumb  the  base  of  the  second 
phalanx  should  if  possible  be  pre- 
served, and  the  soft  parts  must  be  cut' 
correspondingly  longer.  A  digit  may 
be  removed  with  its  metacarpal  by  a  similar  racket  incision,  but  the  handle 
of  the  racket  is  commenced  at  the  base  of  the  bone  to  be  removed.  In  many 
cases  flaps  must  be  made  in  other  manners  according  to  what  remains,  and 
dorsal  or  lateral  flaps  should  be  used  rather  than  sacrifice  a  useful  piece  of 
finger  in  order  to  make  a  classical  stump. 

AFFECTIONS  OF  THE  LOWER  LIMB 

The  Pelvis.  Acute  and  chronic  infections  and  tumours  are  found  in 
this  region. 

(a)  Acute  Infections.  These  occur  most  usually  in  young  persons, 
starting  in  the  juxta-epiphyseal  regions,  as  in  the  case  of  similar  infections 


Fig.  197.  Amputations  of  fingers  and  wrist. 
Little  finger :  Line  of  incision  for  racket 
amputation  at  metacarpophalangeal  joint. 
Ring  finger :  Line  for  amputation  of  the 
finger  with  its  metacarpal  bone.  First  fin- 
ger :  Modified  racket  amputation  at  meta- 
carpo-phalangeal  joint,  a,  Position  of  the 
superficial  palmar  arch,  b,  Anterior  part  of 
the  line  of  an  elliptical  amputation  at  the 
wrist  (radio-carpal  joint)  ;  the  dotted  line 
shows  the  posterior  part  of  the  incision. 


TUBERCULOSIS  OF  PELVIC  BONES  AND  JOINTS  489 

of  long  bones.  The  most  common  seats  of  affection  are  the  ilium,  starting 
at  the  epiphysis  of  the  crest  or  of  the  anterior  inferior  spine  ;  the  ischium 
may  be  involved  from  disease  starting  at  the  epiphysis  of  its  tuberosity. 
Infections  also  may  be  secondary  to  disease  of  the  bladder  or  rectum,  or 
may  be  pysemic  and  puerperal.  When  affecting  the  ilium  the  periosteum 
may  be  stripped  either  inside  in  the  iliac  fossa  or  under  the  gluteals,  while 
in  the  case  of  the  ischium  the  subperiosteal  abscess  will  form  under  the 
gluteals  or  in  the  ischio-rectal  fossa. 

Signs.  The  onset  is  sudden,  with  high  fever,  delirium,  great  depression, 
and  pain  and  tenderness  over  the  affected  bone,  but  owing  to  the  depth, 
swelling  may  not  be  detected  for  some  days.  Where  the  abscess  forms 
under  the  periosteum  of  the  iliac  fossa  the  tumour  resulting  will  resemble 
an  appendix  abscess,  but  is  lower  down  than  is  usual  with  the  latter  condition, 
and  signs  referable  to  infection  of  the  peritoneum  (vomiting,  abdominal 
rigidity,  and  the  facies)  are  not  found,  though  in  both  cases  flexion  of  the 
hip  is  common. 

Diagnosis.  This  is  often  difficult,  and  as  in  other  acute  bone  disease, 
early  operation  is  essential.  It  will  be  necessary  to  explore  cases  where 
there  is  much  tenderness  over  one  of  the  pelvic  bones  associated  with  high 
fever,  rigors,  irritability,  and  delirium. 

Treatment  consists  in  opening  the  abscess  and  freely  removing  all  infected 
bone  from  the  iliac  fossa,  gluteal  region,  or  ischio-rectal  fossa  according 
to  the  place  of  infection.  The  prognosis  is  very  grave  in  the  more  severe 
infections. 

(b)  Tuberculosis  of  the  Pelvic  Boxes  and  Joints.  This  may 
originate  in  the  sacro-iliac  joint  or  in  the  iliac  epiphysis  or  in  the  ischium 
or  pubis  (probably  in  the  triradiate  epiphyseal  cartilage  of  the  acetabulum  or 
by  spread  from  the  hip-joint). 

Where  affecting  one  of  the  bones,  e.g.  the  ilium  or  pubis,  there  is  a 
chronic  swelling  of  the  bone  not  readily  felt  at  first,  with  variable  amount 
of  weakness,  pain  and  tenderness,  which  are  seldom  great.  Radiographs 
will  show  rarefaction  of  the  affected  bone,  and,  later,  cold  abscesses  will 
appear  in  the  iliac  or  ischio-rectal  fossae,  on  the  buttock,  or  in  the  perineum. 

Treatment.  Rest  and  tonic  measures  in  the  recumbent  position,  aspira- 
tion or  opening  of  abscesses.     Bismuth  paste  for  sinuses. 

Tuberculosis  of  the  Sacro-ill\c  Joint.  This  is  usually  found  in 
adults,  originating  in  the  ilium  close  by,  or  in  the  synovial  membrane  of  the 
joint  itself.     In  some  instances  there  will  be  a  history  of  previous  injur}'. 

The  patient  complains  of  a  feeling  of  pain  and  weakness  of  the  lower 
part  of  the  back  on  the  affected  side,  often  described  "  as  if  he  were  falling 
to  pieces."  Pain  may  be  referred  down  the  leg  from  involvement  of  the 
lumbo-sacral  cord.  There  is  a  limp  on  walking,  and  such  movements  as 
walking  or  coughing  increase  the  pain  and  discomfort. 

Signs.  On  examination  the  hip  and  spine  are  freely  movable,  though 
some  pain  may  be  elicited  in  performing  this  examination  unless  the  pelvis 
be  carefully  steadied.     Pressing  the  iliac  crests  together  produces  acute 


I:h»  A  TKXTIiOOK  OF  KHHiERY 

pain  in  the  region  of  the  joint,  which  in  the  absence  of  signs  pointing  to 
disease  of  the  hip  01  spine  may  be  taken  as  proof  of  affection  of  this  joint. 
Later,  abscesses  may  be  found  behind,  over  the  joint,  01  tracking  into  the 
pelvis,  gluteal  region,  or  the  isehio-rectal  fossa.  In  some  cases  there  is 
apparent  lengthening  of  the  leg  on  the  affected  side  from  tilting  of  the 
pelvis  downwards. 

Prognosis  is  not  good  if  abscesses  and  sinuses  form,  as  is  often  the  case, 
but  in  the  absence  of  these  complications  cure  may  be  expected  in  from 
one  to  two  years. 

Treatment.  Recumbency  with  fixation  of  the  spine  and  legs  would  be 
advisable  were  it  not  for  the  difficulty  of  nursing  adult  patients  in  such,  a 
manner.  Fixation  in  a  single  Thomas's  hip-splint  will  give  very  fair  support 
for  adults,  who  form  the  majority  of  cases,  but  even  with  this  fixation  long 
recumbency  is  advisable.  Where  abscess-formation  takes  place  and  does 
not  subside  with  recumbency  it  will  be  necessary  to  attack  the  joint.  The 
best  plan  seems  to  be  to  turn  up  a  flap  over  the  joint  and  with  a  chisel  cut 
through  the  posterior  part  of  the  ilium,  as  this  lies  over  the  joint,  and, 
having  exposed  the  latter  in  this  manner,  remove  carious  bone  and  granu- 
lation-tissue, draining  for  thirty-six  hours — using  all  precautions  to  obtain 
first  intention,  as  in  these  cases  secondary  infection  is  ruinous. 

(c)  Tumours  of  the  Pelvis.  Both  innocent  and  malignant  formations 
occur.  Of  the  former  exostoses  are  the  only  sort  of  any  importance  ;  these 
l  nay  be  removed  with  the  chisel  if  causing  inconvenience.  Myeloid  sarcomas 
sometimes  occur  and  may  be  resected  locally.  The  usual  tumours  here  are 
periosteal  sarcomas,  often  with  much  ossification,  most  usually  occurring 
in  the  hollow  of  the  sacrum  and  invading  the  iliac  fossa. 

Diagnosis  has  to  be  made  from  inflammatory  or  neoplastic  swellings, 
mostly  from  the  gut  or  kidney,  such  as  chronic  appendicitis,  tubercle  or 
cancer  of  the  sigmoid  and  caecum,  and  perinephric  inflammations.  The 
history — especially  as  regards  intestinal  derangements,  the  complete  fixity 
even  when  still  small,  and  the  X-ray  investigation — will  generally  settle  the 
diagnosis. 

Treatment.  The  pelvis  and  lower  limb  have  been  removed  for  such 
conditions  by  the  intar-ilio-abdominal  amputation,  but  it  may  be  doubted 
whether  such  an  operation  is  often  justifiable  in  view  of  the  almost  invariable 
fatal  termination  from  secondary  deposits  even  when  the  primary  growth 
is  more  in  the  periphery,  e.g.  sarcoma  of  the  femur ;  yet,  as  these  growths 
may  be  distressing  from  pressure  on  nerves  and  not  likely  to  be  relieved 
much  by  X-rays  on  account  of  their  depth,  it  may  be  reasonable  to  perform 
this  operation  in  some  cases. 

[nterilio-abdominal  Amputation.  The  chief  points  in  this  operation 
are  : 

(1)  By  an  incision  along  Poupart's  ligament  and  the  iliac  crest  the 
obliques  and  transversalis  muscle  are  divided  from  their  attachments, 
and  the  peritoneum  is  stripped  from  the  iliac  fossa  till  the  common  iliac 
artery  is  reached ;   this  is  clamped  while  the  growth  is  explored,  and  if 


INTERILTO-ABDOMINAL  AMPUTATION  491 

the     operation    seems    feasible    the    vessels    are    divided    between    two 
ligatures. 

(2)  A  second  incision  is  made  down  from  the  posterior  end  of  the  iliuni 
over  the  sciatic  notch,  which  is  cleared  of  glutseus  fibres,  the  gluteal  and 
sciatic  arteries  tied,  the  sciatic  nerve  injected  with  novocain  and  divided ; 
the  piriformis  and  obturator  interims  are  divided.  The  spine  of  the  ischium 
is  cut  through  at  its  base  external  to  the  pubic  vessels  and  nerve  and  the 
ischium  is  divided  into  the  thyroid  foramen  above  its  tuberosity.  The  iliac 
vessels  are  pushed  inwards  and  the  psoas  divided  high  up,  and  the  posterior 
part  of  the  ilium  cut  through  into  the  sciatic  notch  or  disarticulated  at  the 
sacro-iliac  joint. 

(3)  The  internal  flap  is  made  by  cutting  through  the  adductors  of  the 
thigh,  exposing  and  tying  the  femoral  vessels.  The  horizontal  ramus  of 
the  pubis  is  cut  through,  and  the  part  of  the  pelvis  to  be  removed  can  be 
drawn  outwards  and  dissected  off  the  fascial  origin  of  the  levator  ani.  The 
hamstrings  are  now  divided  and  the  limb  removed,  together  with  most  of 
the  ilium,  the  acetabulum,  and  portions  of  the  pubis  and  ischium. 

The  Gluteal  Region.  Prominence  of  the  buttock  may  be  a  racial 
characteristic,  as  in  the  Hottentot,  or  due  to  position  of  the  spine,  being 
marked  in  lordosis  or  associated  with  congenital  dislocation  of  the  hip, 
though  much  of  the  projection  in  these  cases  is  due  to  the  accompanying 
lordosis ;  tumours  of  bone,  abscesses,  and  aneurysms  will  also  cause  fullness 
here.  Flattening  of  the  buttock  and  loss  of  the  gluteal  fold  is  mainly 
due  to  flexion  of  the  hip,  whether  natural  or  from  disease  of  the  joint,  and 
flattening  of  the  buttock  does  not  necessarily  imply  wasting  of  the  muscles 
around  the  hip,  as  is  often  stated,  but  simply  flexion — which,  however,  is 
commonly  found  in  inflammations  of  this  joint. 

(a)  Abscesses  in  the  gluteal  region  may  be  acute  or  chronic.  The  former 
is  usually  the  result  of  suppuration  of  a  hsematoma  under  the  muscles,  the 
latter  from  spread  of  disease  from  the  hip,  spine,  sacro-iliac  joint,  or  from 
bursal  infection. 

(b)  Bursitis  of  the  Gluteal  Region.  The  bursa  over  the  tuber  ischii  may 
be  the  seat  of  chronic  inflammation  with  effusion  from  the  chafing  of  much 
sitting  in  weavers  or  rowing  men  (Weaver's  or  Lighterman's  bottom),  and 
suppuration  may  follow.  More  common  is  an  infection  of  the  bursa  over 
the  great  trochanter  either  with  tubercle  or  some  subacute  pyogenic  organism. 
e.g.  pneumococcus,  leading  to  the  formation  of  abscess,  which  has  to  be 
distinguished  from  secondary  abscess  following  on  disease  of  hip,  spine,  &c. 
Examination  of  the  surrounding  parts  and  radiographs  will  help  in  diagnosis. 

Treatment.  Incision  and  drainage  for  the  acute  suppurative  forms  ; 
excision,  if  possible,  in  the  chronic  types.  Where  excision  is  impossible 
curetting  and  filling  with  bismuth-paste  is  often  of  service. 

Aneurysm  of  the  gluteal  artery  or  hernia  through  the  sciatic  notch  is 
to  be  distinguished  from  the  more  common  abscess  by  pulsation  and  the 
impulse  on  coughing  respectively.  The  treatment  of  these  conditions  is 
considered  under  Vascular  and  Abdominal  Surgery. 


l"-  A  TEXTBOOK  OF  SURGERY 

THE   REGION  OF  THE  HIP,   INCLUDING  THE   UPPER  END 
OF  THE  FEMUR 

The  anatomy  of  this  region  is  described  under  the  Surgery  of  Injuries, 
and  the  reader  is  referred  to  that  section  as  well  for  description  of  certain 
important  measurements,  as  Nelaton's  line,  Bryant's  measurement,  and  the 
bitrochanteric  test  (p.  306).  In  examination  attention  should  be  paid  to  the 
gait.  Limping  is  common  in  affections  here,  though  also  due  to  disease  of 
the  spine,  sacro-iliac  joint,  or  the  lower  part  of  the  limb  ;  hence  in  all  patients 
with  a  limp  the  spine  and  the  rest  of  the  limb  should  be  examined  before 
making  a  diagnosis.  The  movement  of  the  joint  is  tested  with  the  patient 
lying  on  the  back  and  the  pelvis  fixed  by  flexing  the  other  thigh  firmly  on  the 
abdomen  and  holding  it  there.  (Fig.  204.)  The  position  of  the  limb  is  noted, 
flexion  being  often  found,  and  the  movements  of  flexion,  rotation,  abduc- 
tion, and  adduction  compared  with  those  of  the  sound  side.  The  power  of 
extension  is  tested  by  placing  the  patient  on  the  face  and  lifting  the  limb 
from  the  couch,  comparing  with  the  sound  side.  As  fixed  flexion  of  the 
limb  may  be  compensated  by  lordosis  of  the  spine  above,  making  the  limb 
appear  to  be  extended  when  in  reality  flexed,  the  lordosis  must  be  obviated 
by  firmly  flexing  the  other  thigh  on  the  abdomen  till  all  lordosis  is  obliterated. 
A  position  of  ab-  or  ad-duction  is  noted  by  observing  the  relation  of  the 
line  of  the  axis  of  the  limb  to  one  drawn  through  the  anterior-superior  spines 
of  the  ilium.  The  joint  is  palpated  for  enlargement  or  thickening  about  the 
head  of  the  femur  and  deep-seated  abscess,  in  which  case  fluctuation  may  be 
detected,  while  the  movement  of  the  head  is  ascertained  by  palpating  this 
while  the  limb  below  is  rotated  and  it  is  decided  whether  the  head  is  in 
the  normal  position  below  Poupart's  ligament  or  away  from  this,  e.g.  under 
the  glutei.  The  position  of  the  trochanter  is  noted  by  making  Bryant's 
measurement,  the  bitrochanteric  test,  and  drawing  Nelaton's  line.  Exami- 
nation is  made  for  cold  abscesses  at  a  distance  from  the  joint,  and,  finally, 
radiographic  examination  will  often  help  in  greater  accuracy  of  diagnosis. 
The  following  conditions  are  described  :  congenital  defects,  infections,  and 
acquired  deformities. 

(a)  Congenital  Dislocation  of  the  Hip.  This  is  by  far  the  commonest 
of  all  congenital  dislocations,  is  much  more  frequent  in  girls  than  boys,  and 
is  usually  unilateral,  though  bilateral  cases  are  quite  common.  Little  is 
known  about  the  causation.  Possibly  a  few  cases  are  due  to  injury  at  birth, 
such  as  excessive  traction  with  a  blunt  hook  in  difficult  breech  presentations, 
but  in  most  cases  the  cause  lies  with  the  patient  or  the  parent,  and  may  be 
either  due  to  faulty  development  of  the  head  of  the  femur  and  acetabulum 
or  excessive  intra-uterine  pressure  at  some  period  from  deficiency  of  liquor 
amnii.  These  causes  may  act  together.  Error  in  development  must  surely 
play  an  important  part,  since  the  condition  is  sometimes  hereditary  ;  more- 
over, ossification  is  often  delayed  in  the  femoral  head  on  the  affected  side. 

Anatomy.  The  deviation  from  normal  is  more  marked  the  longer  after 
birth  the  hip  is  examined.     Tn  infancy  the  head  of  the  femur  and  the  aceta- 


CONGENITAL  DISLOCATION  OF  THE  HIP 


493 


bulum  may  not  be  far  from  normal  in  shape,  but  the  former  is  stunted  and 
flattened  and  the  latter  flat,  shallow,  and  partly  filled  in  with  fibrous  and 
fatty  tissue.  The  capsule  of  the  joint  is  long  and  lax,  the  neck  is  deformed, 
the  angle  with  the  shaft  being  usually  diminished  (coxa  vara),  less  often 
increased  (coxa  valga),  and  often  twisted  on  the  shaft  so  that  the  head 
looks  forward.     Owing  to  the  laxity  of  the  capsule  and  the  fact  that  the  head 


A  B 

Fie;.   108.     Double  congenital  dislocation  of  the  hips  (aet.  9).     A,  The  prominent 

buttocks  and  great  lordosis  will  be  noted.     B,  Front  view  of  the  same  patient ;  the 

wide  space  between  the  thighs  is  marked. 


is  out  of  position,  the  latter  will  be  movable  (telescopic  movement)  till  a  false 
acetabulum  is  formed.  The  adductor  muscles  are  shortened.  Later,  when 
the  child  has  walked,  these  defects  are  more  marked,  and  increase  up  to  a 
point  with  age.  The  head  rides  up  on  to  the  dorsum  ilii,  and  in  time  a  false 
socket  is  formed,  the  head  being  still  more  flattened,  stunted,  and  twisted  ; 
the  acetabulum  becomes  more  shallow  and  triangular  and  filled  in  with 
fibrous  tissue  ;  the  iliac  portion  of  the  acetabulum,  owing  to  the  lack  of 
the  normal  counter-pressure  of  the  femur,  fails  to  develop  properly.  The 
capsule,  besides  being  overlong,  may  contract  in  its  middle  portion,  becoming 


lit  I 


\  TEXTBOOK  OK  SURGERY 


hour-glass  Bhaped  and  causing  difficulty  in  reduction  of  the  head.  The 
thigh,  owing  to  the  backward  dislocation,  becomes  flexed  on  the  pelvis, 
and  to  allow  of  the  foot  being  placed  on  the  ground  the  pelvis  is  tilted  forward 
and  tluv  lumbal-  spine  assumes  a  position  of  compensatory  lordosis,  which 
is  characteristic  of  this  deformity.  The  adductors,  hamstrings,  and  ilio- 
psoas are  shortened  and  the  external  rotators  lengthened.  The  shortening 
of  the  limb  owing  t<>  dislocation  upward  and  flexion  of  the  thigh  is  compen- 
sated by  tilting  down  of  the  pelvis  on  the  affected  side,  and  in  some  instances 
there  will  be  well-marked  secondarv  scoliosis.     The  alterations  of  the  head 


Fig.  199.     Doubk 


■aital  dislocation  of  the  tips,  the  heads  of  bothfemoraeonthe 
dorsum  ilii  (skiagram). 


and  acetabulum  vary  much  in  different  cases:  in  some  reduction  is  easy 
and  the  head  remains  in  position,  allowing  a  considerable  range  of  movement 
before  dislocation  again  takes  place  ;  in  others,  again,  manipulative  reduc- 
tion  is  impossible  or,  if  effected,  dislocation  will  recur  with  the  slightest 
movement.  The  ease  with  which  this  re-dislocation  occurs  materially  affects 
the  prognosis  for  the  worse. 

Signs.  The  deformity  is  seldom  noted  before  the  child  has  been  walking 
for  some  time,  as  the  earlier  limping  is  often  regarded  simply  as  evidence 
of  deficient  power  in  one  leg,  but  a  few  cases  are  brought  up  for  examination 
before  walking  has  been  attempted  on  account  of  some  deficient  movement 
of  the  affected  leg,  or  the  lump  in  the  buttock  caused  by  the  dislocated  head 
may  lead  to  inquiry  being  made.  We  have  seen  cases  as  young  as  eleven 
months.  When  walking  has  been  acquired  there  will  be  found  in  unilateral 
a   painless  limping,  with  dipping  of  the  pelvis  as  the  affected  and 


CONGENITAL  DISLOCATION  OF  THE  HIP  195 

shortened  limb  is  placed  on  the  ground,  while  lordosis  is  distinct.  On 
examination  the  great  trochanter  will  be  found  above  Nelaton's  line,  the 
vertical  line  of  Bryant's  measurement  will  be  shortened,  abduction  deficient, 
the  adductors  tense,  while  adduction  is  increased  ;  otherwise  passive  move- 
ments will  be  normal.  On  palpating  over  the  femoral  vessels  below  Poupart's 
ligament  there  will  be  found  a  want  of  resistance  as  compared  with  the  sound 
side  owing  to  the  absence  of  the  femoral  head,  which  will  be  discovered 
behind  under  the  gluteal  muscles.  In  young  subjects,  before  a  new  aceta- 
bulum is  formed  the  head  of  the  femur  can  be  pulled  down  on  the  dorsum 
ilii  by  traction  on  the  leg  while  the  pelvis  is  held  fast.  This  "  telescopic 
movement  "  is  characteristic  but  may  not  be  readily  obtained  except  under 
anaesthesia.  In  bilateral  cases  the  attitude  and  gait  are  alike  remarkable. 
There  is  marked  lordosis  with  protrusion  of  the  abdomen  and  buttocks. 
The  legs  look  too  short,  and  on  measuring  the  trochanters  will  be  found  well 
above  Nelaton's  line  on  both  sides.  The  gait  is  waddling  and  the  patient 
soon  becomes  tired  when  walking.  The  other  signs  are  as  in  the  unilateral 
form.  A  good  X-ray  will  show  the  dislocation  at  once  and  the  amount  of 
deformity  of  the  head  of  the  femur. 

Diagnosis.  From  infective  diseases  the  painlessness  and  the  mobility 
of  the  joint,  except  in  abduction,  and  the  freedom  from  abscesses  and 
sinuses,  as  well  as  the  absence  of  the  freely  movable  head  from  the 
acetabulum  and  telescopic  movement,  will  differentiate.  The  shortening 
of  the  limb,  the  raising  of  the  trochanter  and,  if  bilateral,  the  waddling  gait, 
as  well  as  the  limited  abduction,  are  common  to  this  condition  and  coxa 
vara.  But  the  presence  of  the  head  in  its  proper  position  behind  the  femoral 
vessels  and  its  absence  from  the  gluteal  region,  as  well  as  the  absence  of 
telescopic  movements,  will  decide  in  favour  of  the  later  condition.  Also 
the  history  of  limping  since  walking  commenced  in  dislocation  will  usually 
be  given,  while  this  commences  later,  sometimes  after  some  slight  injury  to 
the  joint — in  the  case  of  coxa  vara.  Trendelenberg's  test  also  helps  to 
separate  these  conditions,  and  consists  in  standing  the  patient  on  the 
affected  limb  :  normally  the  gluteal  fold  is  level  on  both  sides,  in  coxa  vara 
the  fold  is  lower  on  the  affected  side,  in  congenital  dislocation  higher. 
Congenital  dislocation  of  the  hip  is  not  uncommon,  and  should  be  always 
expected  and  examination  made  for  this  deformity  when  limping  is  com- 
plained of  in  an  otherwise  normal  child. 

Treatment.  The  principle  aimed  at  is  to  restore  the  head  of  the  femur 
to  its  socket,  to  keep  it  there  for  several  months  and  to  allow  weight  to 
be  taken  on  the  limb  while  in  this  position.  In  this  manner  the  parts  of 
the  joint  become  mutually  adapted  to  each  other,  and  if  treatment  is  com- 
menced early,  in  a  favourable  case,  a  perfect  anatomical  and  functional  result 
may  be  expected.  The  best  method  in  use  at  present  is  that  by  reduction 
and  retention  in  a  plaster-case,  usually  known  as  the  "  bloodless  method 
of  Lorenz." 

To  be  successful  treatment  must  be  commenced  early — under  five  for 
bilateral,  under  seven  for  unilateral  cases — and  may  be  commenced  as  early 


196 


A  TEXTBOOK  OF  SURGERY 


t'iu.  200  (A).  Congenital  dislocation  of  the  hip 
(tracing  of  a  radiograph). 


as  two.  hut  is  of  little  use  before  there  is  some  prospect  of  the  child  walking 
in  the  plaster-case.  In  considerably  older  children  it  is  worth  making  an 
attempt  of  weight-extension  followed  by  manipulation,  as  reduction  may 
be  possible  and,  short  of  experiment,  one  can  never  say  that  it  is  impossible 
up  to  ten  or  twelve  years  of  age.     A  preliminary  examination  will  show 

the  tenseness  of  the  adductors  and 

hamstrings.      Up   to    about    five 

years    these    will    stretch    under 

^~\  V       (  I     %  J  manipulations,  but  later,  if   very 

tense,  it  is  more  reasonable  to 
divide  them  before  manipulating 
than  to  rupture  them  by  great 
violence.  These  preliminary  teno- 
tomies are  followed  by  weight- 
extension  of  the  limb  for  ten  days. 
Reduction  by  manipulation  is 
performed  under  anaesthesia.  The 
first  step  is  to  stretch  the  muscles  : 
first  the  adductors  by  abducting 
and  externally  rotating  the  thigh 
till  they  are  stretched  or  torn ;  then  the  hamstrings  are  stretched  by 
flexing  the  thigh  on  the  abdomen  with  the  leg  extended;  the  extensors 
are  next  dealt  with  by  turning  the  patient  on  the  side  and  extending  the 
thigh  with  the  leg  flexed  at  the  knee.  Reduction  is  now  attempted  as  in 
reducing  a  traumatic  dorsal  dislocation,  the  thigh  being  flexed  on  the  abdo- 
men and  circumducted 
outwards   while   a  fist  1   v^ 

or  wedge  under  the 
great  trochanter  exerts 
counter- pressure  (at  the 
same  time  the  assistant 
steadies  the  pelvis  by 
pressing  on  the  oppo- 
site ilium  with  both 
hands).  Reduction  may 
take  some  time,  for  the 
force  should  be  gradua- 
ted and  no  great  vio- 
lence    used,    repeated 

efforts  of  moderated  power  being  best  lest  the  femur  be  broken  or  its  upper 
epiphysis  torn  off.  Accomplishment  of  reduction  is  usually  obvious  with 
the  characteristic  click,  the  thigh  remaining  fixed  in  a  position  of  right- 
angled  flexion,  abduction,  and  external  rotation.  If  the  limb  be  now 
gradually  brought  down  to  the  extended  position,  at  some  point  the  head 
will  become  again  dislocated.  If  this  occurs  almost  at  once  there  will  be 
difficulty   in   maintaining  reduction,   but  if  the  limb  can  be  extended  a 


Fig.  200  (B). 


Congenital  dislocation  of  the  hip  reduced  and 
in  abduction  (2nd  stage). 


DISLOCATION  OF  THE  HIP 


497 


considerable  distance  before  re-dislocation  takes  place  the  prognosis  is  good, 
as  retention  in  the  proper  position  will  be  easy.  When  the  head  re-dislo- 
cates easily  the  head  should  be  inverted  or  everted  and  the  thigh  very 
fully  flexed  and  abducted  to  find  some  position  where  the  head  is  most 
securely  kept  in  position. 

The  next  step  is  to  fix  the  lower  extremities,  with  the  dislocation  reduced, 
in  plaster,  and  as  a  single  spica  often  does  not  get  a  sufficient  grip  it  is 
usually  best  to  employ  a  double  spica.  A  pair  of  closely  fitting  stockinet 
drawers  are  put  on  and  over  these  a  good  thickness  of  wool,  especially  over 


Fig.  200  C.     Congenital  dislocation  of  both  hips  2  J  years  after  reduction  by  Lorenz' 

^method,  showing  normal  configuration  of  the  bones. 

(Same  patient  as  200  A,  B.) 

the  bony  prominences,  as  the  iliac  crest,  anterior  superior  spine  of  the  ilium, 
and  the  sacrum.  The  wool  padding  is  firmly  bandaged  on  and  over  it  the 
plaster  is  applied,  taking  care  that  the  femoral  head  is  reduced  and  the  limb 
fully  abducted  and  flexed  to  a  right  angle ;  the  sound  limb  is  abducted 
and  flexed  to  a  less  degree.  The  plaster  must  be  very  thick  along  the 
fold  of  the  groin  or  it  will  surely  break,  and  must  fit  firmly  along  the  iliac 
crest.  When  the  plaster  is  complete  and  set,  but  before  it  is  dry,  it  should 
be  trimmed  up  with  a  sharp  knife,  cutting  it  freely  away  in  the  perineum 
and  in  the  popliteal  spaces  so  that  the  knees  are  free  to  move :  the  edges  are 
smoothed  and  the  drawers  pulled  over  these  to  make  all  snug.  The  plaster 
is  best  varnished  when  dry,  especially  in  small  children.  To  keep  the  skin 
under  the  plaster  clean  and  avoid  pressure-sores,  a  strip  of  bandage  is  passed 
down  each  leg  under  the  drawers  (before  applying  the  plaster)  from  the 
waist  to  the  knee  ;  by  pulling  each  end  of  this  alternately  the  skin  under 
i  32 


193  A  TEXTBOOK  OF  SURGERY 

the  plaster  can  !><•  subjected  to  dry  friction  all  over  and  kept  in  good  condi- 
tion. These  "rubbers"  can  be  readily  changed  when  dirty  by  tying  a 
clran  piece  of  bandage  to  one  end  and  pulling  it  through.     Such  plasters 

will  last  from  three  to  four  months  if  the  child  is  well  looked  after  and  free 
from  vermin.  In  bilateral  cases  both  thighs  will  be  incomplete  abduction 
in  the  *'  spread-eagle  "  position.  Walking  should  be  insisted  on  as  soon 
as  possible,  unilateral  eases  being  helped  by  placing  a  patten  on  the  boot 
of  the  affected  side,  which  is  necessarily  shortened  by  the  flexion  and  abduc- 
tion. In  bilateral  cases  a  small  stool  just  allowing  the  feet  to  reach  the 
ground  is  a  great  help  in  the  earlier  stages  of  walking.  This,  causing  the 
replaced  joints  to  bear  pressure,  is  a  most  important  part  of  the  treatment. 


Fig.  201.     I  !ase  of  double  congenital  dislocation  of  the  hip  after  reduction,  retained 
in  plaster  in  the  "  spread  eagle  "  position. 

The  thighs  should  be  kept  in  the  position  of  flexion  to  at  least  a  right  angle 
with  abduction  for  six  months,  and  then  be  brought  down  for  another  three 
months  half-wTay  to  the  extended  position,  after  which  the  plaster  may  be 
omitted  and  active  exercise  and  passive  movements  with  massage  employed, 
which  will  effect  restoration  of  the  functions  of  the  limb  in  about  another 
six  months.  The  above  applies  to  favourable  cases  ;  where  re-dislocation 
takes  place  very  readily  the  position  in  plaster  must  be  maintained  for  abotit 
six  months  longer.  Probably  many  cases  could  be  cured  by  less  than  nine 
months  in  plaster.  But  the  risk  of  re-dislocation  renders  a  fairly  long 
imprisonment  worth  while,  as  after  the  first  few  days  the  position  is  not 
painful  nor  very  inconvenient.  Where  the  head  cannot  be  reduced  into 
the  acetabulum  it  may  be  made  to  rest  below  the  anterior-inferior  spine 
of  the  ilium,  wrhere  it  will  gradullly  form  a  new  socket  and  give  a  very 
fair  result,  though  slight  shortening  will  still  be  present.  In  such  cases 
a  longer  period  of  fixation  in  plaster  will  be  needed. 

The  results  on  the  whole  are  excellent.     In  cases  where  the  dislocation 


SNAPPING  HIP.     ARTHRITIS  OF  THE  HIP  499 

is  reduced  easily  and  does  not  tend  to  become  re-dislocated,  the  joint  after 
a  few  years  can  hardly  be  detected  from  a  normal  hip  (Fig.  200  C) ;  where  the 
reduction  is  below  the  anterior-inferior  spine  the  results  are  not  perfect  but  are 
a  great  improvement  on  the  original  state.  Where  reduction  by  manipulation 
is  unsuccessful  after  several  attempts,  the  question  arises  as  to  whether 
operative  measures  should  be  employed.  These  consist  in  exposing  the 
joint,  freely  dividing  contracted  structures,  enlarging  the  acetabulum, 
replacing  the  head  of  the  femur  and  putting  up  in  plaster.  The  best  access 
to  the  joint  is  by  turning  up  a  flap  of  skin  over  the  great  trochanter,  detaching 
this  temporarily  with  the  attached  gluteal  muscles,  which  gives  a  very 
free  exposure  of  the  joint.  After  replacement  of  the  head  the  capsule  is 
tightened  by  sutures  and  the  trochanter  secured  in  position  with  a  screw. 
This  operation  is  not  to  be  lightly  undertaken,  as  there  is  some  risk  of 
infection  and  a  stiff  joint  may  result.  If  this  plan  be  considered  unadvisable 
there  is  nothing  to  be  done  for  the  bilateral  cases,  but  for  unilateral  disloca- 
tion a  high  boot  should  be  supplied  to  eliminate  the  limping  and  lateral 
curvature  of  the  spine. 

(b)  Snapping  Hip.  This  condition,  which  may  be  congenital  or  follow  some 
injury  or  be  cultivated  voluntarily  by  the  patient  (who  derives  some  satisfac- 
tion from  the  curious  sound  produced),  consists  of  the  production  of  a 
snapping  sound  in  the  region  of  the  hip  following  movements  of  rotation 
in  the  flexed  and  adducted  position.  This  is  sometimes  accompanied  by 
pain  and  weakness  of  the  joint,  but  in  other  instances  it  is  regarded  rather 
as  an  accomplishment  than  a  defect.  This  has  been  regarded  as  a  partial 
subluxation  of  the  hip-joint,  but  is  more  probably  due  (Binnie)  to  a  band 
of  thickened  tissue  running  in  a  vertical  direction  which  slips  backward 
and  forward  over  the  great  trochanter  in  the  movements  described.  The 
band  consists  of  the  thickened  anterior  margin  of  the  gluteus  maximus,  or 
possibly  of  the  tensor  fascia?  femoris,  and  not  the  ilio-tibial  band.  Treatment 
is  not  usually  necessary  or  desired,  but  if  causing  pain  or  discomfort  the 
tense  band  should  be  exposed  and  either  divided  or  sutured  to  a  flap  raised 
from  the  aponeurosis  of  the  vastus  externus.  which  will  control  its  movement 
and  prevent  sliding  in  the  future. 

(c)  Acute  Arthritis  of  the  hip  may  follow  disease  of  the  bones  forming 
the  joint,  especially  the  upper  end  of  the  femur.  Acute  diaphysitis  starting 
under  the  epiphyseal  cartilage  of  the  head  is  inside  the  capsule  of  the  joint, 
and  the  abscess  readily  bursts  into  the  joint.  More  rarely  the  onset  may 
take  place  around  the  triradiate  cartilage  of  the  acetabular  epiphysis.  The 
infecting  agent  in  such  cases  is  usually  the  staphylococcus,  less  often  the 
streptococcus.  The  infection  may  also  be  blood-borne  from  distant  parts, 
as  in  pyaemia,  enteric,  gonorrhoea.  In  the  two  former  the  onset  may  be 
subacute  and  the  affection  escape  notice  till  the  head  is  dislocated  backwards, 
owing  to  the  softening  of  the  capsule.  Rheumatism  also  accounts  for  a 
fair  number  of  cases. 

Signs.  Where  the  onset  is  acute,  as  in  the  types  found  following  bone- 
disease  or  gonorrhoea  and  rheumatism,  the  patient  has  groat  pain  in  the 


A  TEXTBOOK  OF  SURGERY 

hip  with  limping  01  complete  disability  and  fever  and  general  disturbance. 
On'examination  the  joint  is  flexed,  usually  abducted,  and  the  movements  in 
all  directions  limited  and  very  painful.  Later  there  may  be  found  fullness 
in  Scarpa's  triangle.  In  the  ultra-acute  form  following  bone  infection 
there    will   be   in   addition   rigors,   swinging  temperature,   delirium,    and 

itS. 

The  acute  onset,  fixity  of  the  joint,  tenderness,  and  pain  on  attempted 
movement  point  to  the  seat  of  affection.  The  presence  of  other  diseases, 
such  as  gonorrhoea,  enteric  fever,  pyaemia,  may  help  to  settle  the  variety  of 
infection  ;  where  there  is  no  other  disease  present  the  diagnosis  lies  between 
rheumatism,  tubercle  coming  on  acutely,  or  pyogenic  disease  originating 
in  bone.  The  greater  severity  of  symptoms — high  fever,  delirium,  rigors, 
&c. — will  suggest  the  latter  ;  the  affection  of  several  joints  favours  rheuma- 
tism, while  an  affection  of  one  joint  with  mild  general  symptoms  will  be 
an  acute  onset  of  tubercle.  From  psoas  myositis,  whether  from  spinal  or 
appendical  disease,  the  fixity  of  the  joint  in  all  movements  and  not  only 
in  extension  will  differentiate. 

Treatment.  This  will  depend  on  the  diagnosis  of  cause,  since  the  more 
severe  cases  demand  immediate  exploration.  In  the  milder  forms,  such 
as  those  due  to  rheumatism,  gonorrhoea,  enteric,  the  patient  is  placed  in 
the  recumbent  position  and  the  limb  is  placed  on  extension  with  the  thigh 
flexed.  Where  the  condition  is  grave,  as  shown  by  rigors,  high  fever, 
dehrium,  &c,  the  joint  should  be  aspirated,  and  if  pus  is  found  or  if  there 
is  any  doubt  as  to  the  nature  of  the  effusion  the  joint  should  be  opened  by 
the  anterior  incision  and  drained.  It  is  not  easy  to  decide  in  the  more 
severe  conditions  whether  to  be  content  with  drainage  alone  or  to  go  further 
and  remove  the  head  and  part  of  the  neck  of  the  femur,  which  are  often  not 
only  the  site  of  origin  of  the  disease  but  by  their  presence  interfere  with 
drainage  of  the  joint.  Some  severe  cases  recover  with  drainage  only,  but 
in  others  this  is  not  enough.  It  is  therefore  advisable  when  the  initial 
signs  are  very  severe,  or  if  the  condition  does  not  improve  considerably 
within  twenty-four  hours  after  drainage,  to  saw  through  the  neck  of  the 
femur  and  remove  the  head.  In  the  subacute  forms  it  may  in  some  cases 
be  necessary  to  open  an  abscess  in  the  vicinity,  though  often  this  complica- 
tion is  not  present.  Attempts  should  be  made  in  the  milder  cases  to  reduce 
the  head  where  it  has  become  dislocated,  or,  failing  this,  to  obtain  the 
best  position  with  splinting  and  extension  in  the  abducted  position  to 
diminish  the  shortening.  The  same  applies  where  the  head  has  been 
removed.  Later  a  Thomas's  hip-splint  is  applied  till  firm,  bony  ankylosis 
has  taken  place,  which  may  be  corrected  by  osteotomy  if  in  bad  position. 
AN  here  the  condition  quiets  down  on  drainage  alone  early  movements 
should  be  made  to  prevent  ankylosis  of  the  joint. 

(c7)  Tuberculosis  of  the  Hip  (hip-disease,  morbus  coxae).  This  is 
essentially  a  disease  of  childhood  and  adolescence  and  rarely  originates  in 
adults,  though  recrudescence  of  earlier  disease  is  often  found  even  in  those 
of  middle  age. 


TUBERCULOSIS  OF  THE  HIP 


501 


Anatomy.  The  disease  commences  usually  in  bone,  seldom  in  synovial 
membrane,  and  more  often  in  the  upper  end  of  the  femur  than  in  the  aceta- 
bulum. In  the  femur  the  point  of  origin  is  imder  the  articular  cartilage 
or  in  relation  to  the  diaphyseal  side  of  the  epiphyseal  cartilages ;  usually 
in  the  latter  case  as  the  infection  spreads  it  bursts  into  the  joint,  though  it 
may  occasionally  travel  along  the  neck  of  the  femur  to  the  great  trochanter. 

The  cartilage  of  the  head  and  of  the 
acetabulum  becomes  eroded,  the  bone 
carious,  and  the  ligaments  softened  ; 
the  acetabulum  enlarges  and  tends  to 
travel  upwards  on  to  the  dorsum  ilii. 
Both  travelling  of  the  acetabulum  and 
destruction  or,  less  often,  dislocation 
of  the  head  of  the  femur,  result  in  real 
shortening  of  the  femur.  As  in  other 
joints,  recovery  may  take  place  at 
various  stages — if  the  cartilage  has 
escaped,  with  restoration  of  movement 
to  a  greater  or  less  degree  ;  but  if  the 
latter  has  been  destroyed,  with  firm 
ankylosis  either  fibrous  or  bony.  If 
the  disease  progresses  abscess-formation 
will  ensue,  bursting  through  the  cap- 
sule and  pointing  in  front  or  behind 
the  joint — occasionally,  when  the  aceta- 
bulum is  affected,  passing  into  the 
pelvis.  Dislocation  of  the  head,  apart 
from  wandering  of  the  acetabulum,  is 
much  less  common  than  in  the  more 
acute  infections  of  the  joint. 

Signs.  Three  stages  are  commonly 
described,  but  as  authors  differ  in 
their  description  of  these  stages  and 
as  one  of  them  is  uncommon,  only 
occurring  in  certain  cases,  it  will  be 
better  to  make  only  two  stages.  In 
the  first  there  is  no  real  shortening,  i.e.  no  destruction  or  dislocation  of  the 
bones.  In  the  second  stage  there  is  real  shortening  from  one  or  other  of 
these  conditions.  The  early  signs  are  limping  and  pain,  the  latter  referred 
to  the  hip,  but  often  also,  especially  in  children,  to  the  knee,  which  is  not 
surprising  as  much  of  the  nerve-supply  of  the  two  joints  is  of  similar  origin. 
In  some  instances  the  pain  is  slight  and  the  limping  noted  by  onlookers 
rather  than  by  the  patient.  In  most  cases,  however,  there  is  enough  pain 
to  cause  the  patient  to  place  as  little  weight  on  the  limb  as  possible  and 
tread  on  the  tip  of  the  toe  to  avoid  jarring  the  joint.  As  a  result  of  this 
the  pelvis  is  tilted  up  on  the  diseased  side  to  shorten  the  limb,  the  latter 


Fig.  202.  Old  standing  tuberculosis  of 
the  right  hip  with  sinuses  and  ankylosis 
in  adduction  and  flexion.  The  dark  line 
shows  the  tilting  of  the  pelvis  in  an 
attempt  to  bring  the  limbs  parallel. 


-iiL'  A  TEXTBOOK  OF  SURGERY 

being  made  long  enough  to  reach  the  ground  by  extrusion  of  the  foot  at 

tlic  ankle.  In  addition  to  the  tilting  of  the  pelvis  there  is  flexion  of  the 
hip.  which  also  shortens  the  limb,  possibly  to  lessen  shock  with  the  ground. 
or  possibly  due  to  psoas  spasm. 

The  tilting  up  of  the  pelvis  renders  adduction  of  the  limb  on  that  side 
accessary  to  maintain  the  parallel  position  of  the  legs.     This  seems  t"he 


Fig.  203.     Advanced  hip-disease  with  ankylosis  in  a  flexed  position,  showing  the 
lordosis  produced  when  attempting  to  place  the  affected  limb  straight. 

simplest  explanation  of  the  adduction  so  commonly  found  in  early  hip- 
disease,  and  which  is  often  regarded  as  the  .second  stage,  though  there  is 
no  reason  to  believe  that  in  most  cases  any  previous  stage  has  existed.  The 
patient  is  examined  lying  on  the  back  as  described  above.  All  movements 
will  be  found  restricted  ;  often  the  joint  is  quite  rigid.  The  sound  thigh 
should  be  acutelv  flexed  on  the  abdomen  to  eliminate  the  lordosis  which 


Pig.  204.     The  lordosis  being  eliminated  by  fully  flexing  the  Bound  thigh,  the  degree 
of  real  flexion  of  the  affected  side  becomes  apparent. 

usually  compensates  for  the  flexion  of  the  hip-joint,  and  this  will  show  the 
amount  of  flexion  that  is  really  present.  (Figs.  203,  204. )  Flexion,  extension 
rotation,  ab-  and  adduction  will  all  be  limited  and  painful  when  attempted, 
especially  when  attempt  is  made  to  place  the  limb  in  the  fully  abducted, 
and  everted  or  "  tailor's  position."  On  turning  the  child  over  the  gluteal 
fold  will  be  found  diminished  or  absent  (sign  of  flexion  of  the  joint)  and 
the  affected  limb  cannot  be  extended,  i.e.  lifted  as  far  off  the  couch  as  the 
sound  limb.     The  amount  of  muscular  wasting  may  be  slight  but  will  be 


DIAGNOSIS  OF  HIP-DISEASE  .503 

obvious  after  a  few  weeks.  In  most  of  these  cases  the  limb  affected  appears 
shorter  than  the  other ;  measurement,  however,  will  show  that  there  is  no  true 
shortening  but  the  illusion  is  due  to  tilting  up  of  the  pelvis,  which  is  oblique 
to  the  long  axis  of  the  body  (a  line  through  the  anterior-superior  spines  will 
show  this). 

'  In  a  few  cases  the  affected  limb  appears  longer  than  the  other,  and 
investigation  will  show  that  this  is  due  to  abduction  of  the  limb  with  tilting 
down  of  the  pelvis  on  the  affected  side.  The  explanation  given  is  that 
in  the  flexed,  abducted  and  everted  position  the  capsule  of  the  joint  can 
contain  more  fluid  than  in  any  other,  and  that  this  position  is  assumed  for 
greater  comfort  when  there  is  much  fluid  in  the  joint.  This  position  is 
sometimes  called  the  first  stage,  but  is  seldom  found  on  examination  ;  nor 
is  this  hard  to  explain,  since  tubercle  does  not  often  commence  in  the  synovial 
membrane  and  so  cause  effusion  into  the  joint.  It  usually  originates  in 
the  bone,  causing  tenderness  on  pressure  (of  walking  and  standing),  with 
the  resulting  upward  tilting  of  the  pelvis  and  secondary  adduction  of  the 
limb.  In  the  case  of  abduction  due  to  effusion  the  tilting  of  the  pelvis  is 
secondary,  to  place  the  limbs  again  parallel,  and  is  found  more  often  in 
acute  affections  with  effusion  than  in  tuberculosis,  and  therefore  should 
not  be  called  the  first  stage,  being  only  one  form  of  this.  As  the  disease 
progresses  and  passes  into  the  second  stage  the  patient  complains  of  starting- 
pains  at  night  (evidence  of  destruction  of  cartilage),  there  is  marked  wasting 
of  muscles,  and  the  destruction  of  bone  will  be  obvious  in  radiograms.  The 
limb  is  more  flexed  and  adducted,  whatever  was  the  primary  position,  while 
true  shortening  of  the  femur  with  alteration  in  the  relation  of  the  great 
trochanter  to  Xelaton's  line  shows  that  there  is  destruction  or  dislocation  of 
the  head  or  travelling  of  the  acetabulum. 

In  this  stage  or  earlier,  cold  abscesses  may  be  found  as  painless  fluctua- 
ting swellings,  which  in  front  appear  between  the  sartorius  and  tensor 
fasciae  femoris  or  to  the  inner  side  of  the  vessels  or  posteriorly  passing  along 
the  external  rotators  at  the  lower  border  of  the  gluteus  maximus,  less  often 
passing  through  the  acetabulum  into  the  pelvis  or  along  the  iliacus  sheath 
to  form  an  iliac  abscess,  or  occasionally  into  the  ischio-rectal  fossa.  Still 
later,  especially  if  neglected,  the  abscesses  burst,  forming  sinuses  which 
become  infected  with  pyogenic  organisms,  and  the  patient  suffers  from 
hectic  fever  with  swinging  temperature,  sweats,  wasting  ;  and  still  later 
there  may  be  albuminuria  or  other  signs  of  lardaceous  disease. 

Diagnosis.  From  other  conditions  causing  limping  the  diagnosis  is  made 
by  examining  the  whole  limb  and  spine,  testing  all  joints.  In  this  way 
one  will  avoid  the  perennial  error  of  mistaking  early  hip  disease  for  some 
obscure  condition  of  the  knee  with  pain  and  limping  but  no  physical  signs. 
The  position  and  rigidity  of  the  hip  will  show  at  once  which  joint  is  affected. 
From  congenital  dislocation  of  the  hip  and  coxa  vara  the  diminished  mobility 
in  all  directions  (not  only  in  abduction),  the  pain  on  jarring  the  heel  or  knee, 
the  absence  of  telescopic  movement  (in  the  case  of  congenital  dislocation), 
and  the  appearance  under  X-rays  will  readily  distinguish.     The   X-ray 


504  A  TK  XT  BOOK  OF  srRCJERY 

picture  of  the  two  latter  conditions  is  clear,  but  there  may  be  nothing 
obvious  in  early  tuberculosis  of  the  joint,  though  later  caries  or  haziness 
of  the  joint  from  effusion  will  be  noted.  Later  starting-pains,  muscular 
wasting,  and  abscess-formation  will  clearly  indicate  hip  disease.  In  sacro- 
iliac disease  the  free  movement  of  the  joint  if  the  pelvis  is  steadied,  the 
pain  on  pressing  the  iliac  crests  together,  will  distinguish.  In  psoas 
myositis — whether  secondary  to  spinal  disease,  appendicitis,  or  infection 
of  the  bursa  under  the  muscle — the  mobility  is  only  impaired  in  extension, 
other  movements  being  free,  while  there  is  no  pain  on  jarring  the  limb. 
From  cases  of  separated  epiphysis  of  the  femoral  head  leading  to  coxa 
vara,  the  diagnosis  rests  on  the  history,  the  immediate  appearance  of  real 
shortening  with  a  quite  short  history  of  disability,  and  the  radiographic 
picture  (in  both  instances  movements  are  all  impaired).  From  acute  infec- 
tions the  general  condition,  rapidity  of  onset,  or  the  presence  of  other 
disease,  e.g.  gonorrhoea,  will  separate. 

From  new  growths  of  the  upper  end  of  the  femur  the  greater  mobility 
of  the  joint  in  such  cases  at  first  will  help  to  distinguish,  but  radiograms 
are  absolutely  necessary  to  make  a  certain  diagnosis. 

In  neuromimetic  joints  (hysteria)  the  gross  exaggeration  of  the  position 
compared  with  the  pain  and  disability  is  the  safest  clue  to  follow.  When 
the  hip  is  found  after  two  days  flexed  to  less  than  a  right  angle,  while  the 
patient  looks  well  and  has  normal  temperature  and  digestion,  one  may 
safely  exclude  acute  infection  or  tuberculosis  of  the  joint. 

Bilateral  Hip  Disease.  This  presents  similar  signs  to  the  affection 
of  the  joint  on  either  side,  but  the  disability  is  greater  when  healing  by 
ankylosis  has  taken  place,  especially  if  both  limbs  have  been  allowed  to 
assume  the  adducted  position  ("  scissor  deformity  "),  when  walking  will  be 
almost  impossible,  and  even  if  the  limbs  are  slightly  abducted  progression 
will  be  toilsome.  In  this  case  the  question  of  attempting  an  arthroplasty 
of  at  least  one  joint  must  be  considered,  but  for  this  to  be  successful  much 
time  must  be  allowed  to  elapse,  so  that  the  joint  is  soundly  healed  and  the 
risk  of  causing  a  recrudescence  is  reduced  to  a  minimum. 

Prognosis.  This  is  not  bad  under  favourable  conditions  of  outdoor 
life  and  good  feeding  :  as  in  other  tuberculous  conditions,  poverty  and  care- 
lessness are  the  patient's  worst  enemies.  The  process  of  healing  is  slow  and 
can  seldom  be  considered  complete  under  one  and  a  half  to  two  years — often 
longer  if  sinuses  develop  and  much  destruction  of  bone  takes  place.  Death 
from  general  spread  of  tuberculosis,  from  lardaceous  disease  or  sepsis  arising 
in  sinuses,  carries  off  a  certain  number  of  patients. 

Treatment.  The  greater  number  of  cases  will  recover  on  rest,  good 
feeding,  and  open-air  treatment,  combined  with  local  care  of  the  joint, 
which  should  be  put  at  rest  and  guarded  from  pressure  and  jarring.  In 
the  earlier  stages  all  movements  are  best  avoided.  Operative  treatment 
is  only  advisable  where  the  condition  is  rapidly  advancing  in  spite  of  con- 
servative treatment,  and  in  cases  where  abscesses  or  sinuses  are  increasing 
or  general  infection  is  threatening. 


TREATMENT  OF  HIP-DISEASE 


505 


Fig.  205.     Double  Thomas's  hip-splint. 


Local  Measures.  Before  the  limb  is  fixed  on  a  splint  the  position 
must  be  corrected,  so  that  instead  of  being  flexed  and  adducted  it  will  be 
almost  fully  extended  and  slightly 
abducted.  The  best  plan  of  getting 
the  limb  down  from  its  flexed  position 
is  by  weight-extension  in  the  axis  of 
the  limb  ;  some  such  modification  as 
Walton's  of  the  box-splint  is  useful  for 
this  purpose,  pp.  313.  316.  319.    Care 

is  needed  that  the  lordosis  does  not  recur  as  the  flexed  limb  is  brought  down 
into  the  extended  position.  The  weight  used  varies  from  one  to  six  pounds 
according  to  the  size  of  the  patient,  and  the  limb  is  brought  down  a  few  degrees 

every  second  or  third  day,  a  fortnight 
being  about  the  time  needed  to  obtain 
good  position.  Having  corrected  the 
position,  the  limb  is  fixed  by  applying  a 
single  Thomas's  splint,  with  a  patten  on 
the  boot  of  the  sound  limb  to  prevent  the 
foot  of  the  affected  side  coming  in  contact 
with  the  gTound.  This  applies  in  those 
old  enough  to  use  crutches  ;  in  smaller 
children  the  recumbent  position  in  a  double 
Thomas's  splint,  of  which  the  leg-irons  are 
in  slight  abduction,  will  give  good  results. 
Instead  of  this  form  of  splinting  plaster- 
casing  may  be  used,  but  is  cumbrous,  and 
if  abscesses  are  forming  does  not  so  readily 
permit  of  inspection.  In  all  cases,  whether 
iron  or  plaster  splints  are  used,  the  affected 
foot  should  be  well  off  the  ground  ;  it  is 
useless  to  prevent  movement  of  a  joint 
while  allowing  it  to  be  subjected  to  inter- 
articular  pressure  from  jarring  its  extremity 
on  the  ground.  The  splint  should  be  worn 
at  least  a  year  in  most  cases,  or  for  about 
six  months  after  all  signs  of  active  disease 
have  disappeared.  Such  signs  are  pain,  ten- 
derness on  jarring,  and  abscess-formation. 
The  patient  will  place  weight  very  gradually 
on  the  limb,  removing  the  patten  but  using 
at  first  crutches,  later  a  stick  for  some 
months,  till  it  is  certain  that  all  is  well.  During  confinement  in  splints  mas- 
sage of  the  limb  will  maintain  its  nutrition,  but  movements  are  to  be  avoided 
till  the  splint  is  removed  and  then  attempted  very  gently.  Abscesses  are 
treated  on  general  principles,  the  recumbent  position  being  assumed  and  aspir- 
ation or  incision  practised  if  the  former  is  not  enough  to  cause  subsidence. 


FlG.  206.     Thomas's  hip-splint. 


A  TEXTBOOK  OF  SURGERY 

Operative  Treatment.  This  is  never  indicated  in  recent  cases,  since  the 
prospects  of  recovery  are  on  the  whole  so  good  under  conservative  treat- 
ment, and  interference  with  the  head  will  impair  the  growth  of  the  limb, 
causing  great  shortening.  Indications  for  operation  are  extensive  and 
progressive  disease,  especially  if  infected  sinuses  are  present  and  the  disease 
is  spreading  up  the  neck  of  the  femur  or  in  the  acetabulum.  In  such  cases 
a  free  excision  may  considerably  cut  short  the  duration  of  the  disease  and 
diminish  the  risks  from  prolonged  suppuration,  while  in  such  severe  cases 
there  must  be  shortening  of  the  limb  whatever  is  done.  Since  before  this 
operation  is  contemplated  sinuses  will  often  have  been  scraped  and  injected 
with  bismuth,  &c.,  an  incision  allowing  of  free  inspection  and  drainage  is 
needed,  and  consequently  the  posterior  route  of  Kocher  is  usually  advisable 
for  tuberculosis,  reserving  the  anterior  incision  for  simple  drainage  or 
excision  in  cases  of  acute  bone-infection.  In  such  an  incision  the  sinuses 
should  be  included  if  possible  and  excised,  all  diseased  bone  removed, 
including  the  upper  end  of  the  femur  and  the  acetabulum  if  necessary, 
as  well  as  diseased  synovial  membrane  and  other  soft  tissues.  The  wound 
is  closed  with  drainage  for  two  days  and  put  up  on  an  abduction  box-splint 
to  produce  apparent  lengthening  of  the  necessarily  shortened  limb  by  tilting 
the  pelvis. 

Amputation.  This  is  indicated  where  excision  fails  and  infection  spreads 
into  the  pelvis  or  along  the  shaft  of  the  femur  and  hectic  fever  or  lardaceous 
disease  supervene,  or  where  sinuses  persist  in  spite  of  treatment  and  the 
joint  is  flail-like  and  useless,  the  disease  being  still  active.  The  external 
racket  incision,  either  by  Furneaux  Jordan's  method  or  with  temporary 
clamping  of  the  common  iliac  artery  through  a  gridiron  incision,  is  suitable 
for  this  amputation  (p.  512). 

(e)  Chronic  Rheumatoid  Affections  of  the  Hip.  These  are  very 
common,  especially  in  middle-aged  and  elderly  persons,  and  often  is  a 
sequel  to  injury  of  the  joint,  which  perhaps  may  be  regarded  as  the  place 
of  election  for  traumatic  osteo-arthritis. 

Diagnosis.  This  is  usually  easy  :  the  age,  pain,  and  defective  movement 
with  grating  going  on  to  ankylosis,  the  lipping  and  deformity  with  shortening 
of  the  limb  and  diminution  of  the  angle  of  the  neck,  as  seen  with  X-rays 
or  found  by  noting  the  position  of  the  great  trochanter  with  regard  to 
Nelaton's  line,  form  a  characteristic  picture  in  well-marked,  instances. 

Treatment  has  been  mostly  palliative  in  the  shape  of  massage,  hot-air 
baths,  iodides,  iron,  arsenic,  &c,  which  relieve  for  a  time  and  may  be  worth 
continuing  over  long  periods  in  the  more  slowly  advancing  cases.  Where 
pain  and  disability  from  ankylosis  result  in  persons  otherwise  strong  and 
well,  especially  if  the  condition  be  bilateral,  the  operation  of  arthroplasty 
seems  to  be  justified,  and  good  results  are  claimed  for  this  procedure  by 
Murphy. 

(f)  Neuropathic  Disorders  (Charcot)  are  fairly  often  met  with  in 
tabes,  the  joint  rapidly  and  painlessly  filling  with  effusion,  the  head  of 
the  femur  being  destroyed  or  dislocated,  leading  to  a  flail  joint.     The  rapid 


COXA  VARA  507 

and  painless  disorganization  of  the  joint  and  the  other  signs  of  tabes  render 
diagnosis  easy. 

Treatment.  The  condition  may  be  palliated  or  even  improved  tem- 
porarily by  the  use  of  a  Thomas's  calliper  knee-splint,  which  takes  the 
pressure  off  the  joint,  permitting  some  use  of  the  limb,  or  a  Thomas's  hip- 
splint  may  be  used  with  crutches  and  a  low  patten  on  the  sound  side. 

(g)  Neuromimesis  (hysterical  hip).  This  condition  is  more  frequent 
in  the  hip  than  in  any  other  joint,  and  has  been  described  in  the  section 
on  Affections  of  Joints  in  General  (p.  417). 

(h)  Deformities  of  the  Neck  of  the  Femur  (coxa  vara  and  coxa 
valga).  Under  various  conditions  the  angle  which  the  neck  of  the  femur 
makes  with  the  shaft  (normally  about  130°)  may  be  increased  or  diminished — 
the  former  condition  being  known  as  coxa  valga,  the  latter  as  coxa  vara. 
of  which  the  latter  is  by  far  the  more  important  condition. 

(1)  Coxa  Vara.  Diminution  of  the  angle  of  the  femoral  neck  arises 
at  three  periods  of  life  from  different  causes.  In  small  children  softening 
of  the  bone  from  rickets  allows  the  weight  of  the  body  to  bend  the  femoral 
neck  to  less  than  the  normal  angle,  just  as  bending  occurs  in  other  bones. 
In  older  children  and  adolescents  separation  of  the  epiphysis  for  the  head 
of  the  femur  (partial  or  complete)  accounts  for  a  good  many  cases.  The 
neck  slips  up  on  the  head  and  the  direction  of  the  growing  surface  is  altered, 
so  that  new  bone  is  laid  down  in  a  direction  corresponding  to  an  angle 
of  90°  or  less  with  the  shaft  of  the  femur.  In  old  persons  rarefaction 
associated  with  osteo- arthritis  leads  to  shortening  of  the  neck  and  diminution 
of  its  angle.  In  addition  to  the  diminution  of  the  angle  of  the  neck  there 
is  a  curvature  of  the  neck  forwards,  so  that  the  patella  and  foot  are  everted. 

Signs.  In  the  adolescent  type  there  will  usually  be  a  history  of  some 
slight  injury  to  the  hip  which  was  disregarded  but  followed  by  "some  stiffness 
and  disability,  for  in  many  cases  of  separation  of  the  epiphysis  the  patient 
can  walk  fairly  well  at  first.  Later  the  defect  becomes  more  pronounced 
with  pain,  limping  (from  the  shortened  leg),  eversion  of  the  foot,  and  the 
patient  soon  becomes  tired  in  the  affected  limb.  On  examination  the 
trochanter  is  prominent,  further  back  than  normal,  and  raised  above 
Nelaton's  line,  the  muscles  of  the  thigh  and  buttock  somewhat  wasted. 
As  regards  movements,  the  one  most  affected  is  abduction,  which  may  be 
completely  lost  if  the  deformity  is  great ;  flexion  may  also  be  affected.  In 
the  earlier  stages  all  the  movements  are  much  affected,  though  abduction 
more  than  the  others,  and  these  recover  considerably  as  time  elapses  after 
the  initial  lesion.  Eversion  of  the  limb  is  usually  marked,  inversion  being 
much  diminished  ;  it  will  be  found  that  the  patella  cannot  be  made  to 
rotate  further  inward  than  the  mid-line.  Where  the  deformity  is  bilateral 
the  gait  is  waddling,  as  in  cases  of  bilateral  dislocation  of  the  joint,  and 
in  more  severe  degrees  a  "  scissor-deformity  "  may  be  present,  the  adducted 
limbs  crossing  each  other  and  rendering  progression  very  difficult. 

Diagnosis.  The  history  and  rapid  appearance  of  deformity  soon  after 
the  onset,  the  defect  of  movement,  principally  affecting  abduction,  and, 


A  TEXTBOOK  OF  SURGERY 


later,  the  absence  of  signs  of  inflammation  or  abscess  though  deformity 
1"'  great,  will  distinguish  from  tuberculosis  of  the  joint.  From  congenital 
dislocation  the  recent  acquirement  of  a  limp,  the  absence  of  telescopic 
movement,  and  Trendelenberg's  test  (see  Congenital  Dislocation)  will 
decide.     In  slight  cases  radiograms  are  a  valuable  help. 

Treatm  vt.     Since  a  large  number  of  these  cases  follow  separation  of 
tin1  upper  femoral  epiphysis  and  this  may  be  missed  when  incomplete,  it  is 


l 


NORMAL 


COXA  A/ALGA 


Fig.  207.     f'oxa  vara  and  valga.     I,  IT,  III,  Different  angles  of  the  femoral  neck. 
I  V.  Slipping  of  the  neck  of  the  femur  off  the  upper  epiphysis  leading  to  coxa  vara. 


important  to  take  radiographs  of  slight  injuries  to  the  hip  in  children  if 
tenderness  and  rigidity  persist  after  a  few  days,  and  if  separation  of  the 
epiphysis  is  discovered  to  place  the  patient  in  a  box-splint  with  full  abduction 
or,  better,  to  fully  abduct  and  invert  the  limb  under  anaesthesia  and  place  in 
a  longplaster-spica  from  thecostal  margin  to  the  ankle  (Whitman).  (Fig.  127.) 
After  remaining  in  the  abducted  position  six  weeks  a  Thomas's  knee-splint 
should  be  worn  for  four  months  to  prevent  the  recently  united  epiphysis 


ANKYLOSIS  OF  HIP  509 

from  becoming  again  displaced.  Where  the  condition  of  coxa  vara  is  of 
some  standing  but  not  severe,  as  in  early  cases  due  to  rickets  or  where  a 
displacement  of  the  epiphysis  is  slight,  the  weight  of  the  body  should  be 
taken  off  the  limb  by  means  of  a  Thomas's  knee-splint  for  about  a  year ; 
the  weight  of  the  limb  will  act  as  extension  and  then  give  the  neck  a  chance 
of  growing  straight  again.  Where  severe  deformity  is  already  present  in 
young  patients  an  osteotomy  should  be  done,  the  femur  being  divided 
downwards  and  inwards  between  the  trochanters  and  the  limb  put  up  in 
marked  abduction  on  a  box-splint  with  inversion  of  the  foot.  In  more 
severe  cases  where  the  angle  of  the  neck  is  less  than  ninety  degrees,  a  wedge 
of  bone  may  be  removed  in  the  same  situation  (cuneiform  osteotomy)  and 
the  adductors  divided  if  tense,  the  hmb  being  put  up  in  abduction  as  before 
and  this  followed  by  the  use  of  the  knee-splint  for  some  months  to  prevent 
recurrence.     Senile  cases  are  treated  as  for  osteo-arthritis. 

(2)  Coxa  Volga.  This  condition  may  be  considered  to  be  present  when 
the  angle  of  the  femoral  neck  exceeds  140°  (Tubby).  It  may  follow 
rickets  or  separation  of  the  epiphysis,  but  is  more  often  associated  with 
congenital  dislocation  or  infantile  paralysis. 

Signs.  The  limb  is  overlong,  the  great  trochanter  being  below  Xelaton's 
line  ;  abduction  and  eversion  are  present.  There  may  be  some  impairment 
in  the  gait.  Where  causing  trouble,  confinement  in  plaster-spica  for  some 
months  in  the  adducted  position  may  improve  the  condition. 

(h)  Ankylosis  following  Disease  of  the  Hip.  This  is  in  most  cases 
the  best  result  that  can  be  obtained  after  acute  infection  or  tuberculosis 
of  the  joint,  though  in  a  few  cases  a  movable  joint  will  result.  Ankylosis, 
however,  to  be  satisfactory  must  be  in  good  position,  i.e.  the  thigh  must 
be  almost  fully  extended  and  slightly  abducted  (to  compensate  for  the  true 
shortening  usually  present).  In  neglected  cases  ankylosis  usually  takes 
place  in  a  position  of  considerable  flexion  and  adduction,  leading  to  great 
apparent  and  functional  shortening  of  the  limb  with  compensatory  lordosis 
to  a  degree  often  very  embarrassing  to  the  patient.  For  slight  cases  a  high 
boot  may  be  sufficient. 

To  counteract  the  faulty  position  when  severe,  osteotomy  of  the  upper 
end  of  the  femur  will  be  needed.  Since  in  most  cases  the  neck  of  the  bone 
is  largely  destroyed  by  the  preceding  osteitis,  division  of  this  (Adams's 
osteotomy)  will  seldom  be  possible,  and  in  any  case,  owing  to  the  smaller 
size  of  the  bone  here,  is  less  likely  to  give  good  bony  union  than  osteotomy 
lower  down.  Consequently  the  femur  should  be  divided  just  below  (Gant) 
or,  better,  between  the  trochanters  (Maunder)  with  an  osteotome,  which 
is  introduced  an  inch  and  a  half  below  the  tip  of  the  great  trochanter, 
the  limb  afterwards  being  put  up  in  slight  abduction  with  extension. 
This  may  be  maintained  for  four  weeks,  when  the  limb  may  be  placed 
in  a  plaster-spica  for  four  months  before  walking  is  allowed  on  the 
corrected  limb. 

(i)  Burs,e  about  the  Hip- joixt.  The  bursse  over  the  great  trochanter 
may  be  the  seat  of  simple,  acute,  pyogenic,  or  tuberculous  inflammation. 


510  A  TEXTBOOK  OF  SURGERY 

When  an  abscess  results,  whether  acute  or  chronic,  there  will  be  swelling 
in  this  region  and  some  limitation  of  movement  of  the  joint,  but  some 
movement  will  be  possible  in  all  directions;  nor  will  there  be  any  pain 
on  jarring  the  joint  as  in  hip-disease,  with  which  bursitis  may  otherwise 
be  confused. 

Inflammation  of  the  bursa  under  the  psoas-tendon  may  occur  from 
any  of  the  above  causes,  and  is  distinguished  from  disease  of  the  hip 
by  the  fact  that,  though  flexion  of  the  joint  is  marked,  yet  the  only  move- 
ment defective  is  extension,  and  there  is  no  pain  on  jarring  the  joint  nor 
any  real  shortening  :  a  fluctuating  swelling  may  be  noted  in  Scarpa's 
triangle. 

Treatment  is  as  for  bursitis  generally  ;  rest,  incision,  and  drainage  or 
curetting,  and  injection  of  bismuth-paste,  according  to  the  underlying 
cause. 

OPERATIONS   ABOUT  THE  HIP-JOINT 

(1)  Aspiration  (exploratory)  or  Injection  op  the  Joint.  A  needle 
driven  horizontally  inwards  from  the  side,  immediately  above  the  tip  of 
the  great  trochanter,  will  enter  the  joint,  the  bone  it  reaches  being  the 
head  of  the  femur.     Effusion  may  be  aspirated  or  vaseline,  &c,  injected. 

(2)  Arthrotomy  and  Excision.  The  joint  may  be  reached  by  an 
anterior  or  posterior  route.  The  former  is  advised  where  there  is  a  proba- 
bility of  simply  opening  and  draining  the  joint  or  removing  the  head  of 
the  femur,  as  in  cases  of  acute  infection.  The  latter  approach  is  more 
suitable  in  advanced  cases  of  tuberculosis  where  operation  is  advisable,  as 
the  exposure  is  much  more  thorough  and  drainage  more  efficient,  though 
more  damage  to  soft  parts  is  unavoidable. 

(a)  The  Anterior  Route.  A  three-  or  four-inch  incision  is  made  vertically 
down  from  the  anterior-superior  spine  between  the  sartorius  and  tensor 
fasciae  femoris  ;  next  the  incision  passes  between  the  glutei  and  rectus 
femoris,  the  branches  of  the  external  circumflex  artery  being  tied  and  divided 
if  necessary.  The  capsule  of  the  joint  is  now  exposed  and  opened.  The 
operation  may  stop  at  this  point  with  drainage  of  the  joint,  or,  if  necessary, 
the  neck  of  the  femur  be  divided  with  osteotome  or  Adams's  osteotomy 
saw  and  the  head  and  part  of  the  neck  torn  out  of  the  socket  dividing  the 
ligamentum  teres,  scraping  out  necrotic  tissue,  and  draining.  The  limb 
is  put  up  in  the  abduction  box-splint  with  moderate  extension. 

(6)  The  Posterior  Route.  A  five-  or  six-inch  incision  is  made  over  the 
great  trochanter — the  lower  part  being  vertical,  the  upper  inclining  backwards 
parallel  with  the  fibres  of  the  gluteus  maximus.  The  latter  is  split  obliquely 
above,  vertically  below7,  and  the  great  trochanter  exposed.  This  is  detached 
from  the  shaft  with  the  chisel  and  displaced  up  with  the  attached  muscles 
(gluteus  medius  and  minimus,  pyriformis  and  obturators).  The  capsule  is 
freely  exposed  and  incised  longitudinally,  the  head  dislocated,  and  the 
acetabulum  examined.  In  most  cases  requiring  this  operation  it  will  be 
necessary  to  remove  the  whole  head  and  neck  of  the  bone  and  gouge  out 


AMPUTATION  AT  THE  HIP 


511 


the  acetabulum  till  all  diseased  bone  and  synovial  membrane  are  removed. 
The  wound  is  closed  with  drainage,  replacing  the  detached  trochanter  if  not 
diseased.  The  limb  is  splinted  in  abduction  as  before,  and  later  placed  in 
a  Thomas's  hip-splint,  no  weight 
being  taken  for  at  least  six  months 
after  healing  has  occurred. 

(3)  Amputation  at  the  Hip- 
joint.  Indications,  (a)  For  severe 
injuries  high  up  the  lower  limb  or 
sepsis  and  gangrene  arising  from 
these.  In  the  former  cases,  owing 
to  the  initial  shock  of  the  accident, 
the  added  shock  of  operation,  which 
may  be  great,  is  likely  to  prove 
deadly.  Hence  in  these  cases  some 
hours  should  elapse  after  the  injury 
before  amputation  is  performed, 
while  the  patient  is  revived  by 
morphia  and  saline  infusions  ;  at  the 
amputation  nerve-blocking  should 
be  carefully  practised,  the  intra- 
spinal method  being  very  suitable 
for  these  cases. 

(6)  Advanced  cases  of  tubercu- 
losis of  the  joint  not  yielding  to 
excision,  or  where  in  older  patients 
the  infection — as  shown  by  sinuses, 
hectic  fever,  and  lardaceous  disease 
— has  advanced  to  such  a  degree 
that  excision  seems  hopeless. 

(c)  Malignant  growths  of  the 
upper  end  of  the  femur.  Owing 
to  the  extreme  rarity  of  cures  from 
amputation  in  these  cases  the 
legitimacy  of  the  operation  is  often 
questionable.  But  where  there  is 
great    pain    in    a    useless    limb    or 

fungating  ulceration  and  attacks  of  secondary  haemorrhage  there  will  be 
no  hesitation  in  amputating  at  the  hip.  The  main  dangers  of  this  opera- 
tion are  shock  and  haemorrhage.  Shock  is  generally  attributed  to  sec- 
tion of  the  large  nerves  (sciatic  and  anterior  crural),  but  varies  greatly ; 
some  patients  are  hardly  affected,  while  others  suffer  severely  from  syncope 
and  may  nearly  die  on  the  table.  The  indication  is  to  block  the  nerves  by 
using  spinal  anaesthesia  or  injecting  novocain  into  them  shortly  before 
division.  Haemorrhage  in  this  operation  has  taxed  the  ingenuity  of  surgeons 
for  generations,   and  much  inventive  genius  has  been  expended  in  the 


Fig.  208.  I,  Disarticulation  of  the  hip- 
joint  by  external  racket  incision.  II,  Pos- 
tero  -external  angled  incision  (Kocher)  for 
excision  of  the  hip-joint.  (The  length  of  the 
incision  is  exaggerated  in  the  diagram.) 


512  A  TKXTBOOK  OF  SURGERY 

production  of  clamps,  metal  levers,  bands,  pins,  &c,  but  the  simplest  plan 
is  temporarily  to  occlude  the  common  iliac  artery  or  to  use  the  excellent 
method  of  Furneauz  Jordan.  The  common  iliac  artery  can  readily  be 
reached  by  a  gridiron-incision  in  either  iliac  fossa,  splitting  the  muscles. 
The  peritoneum  and  transversalis  fascia  are  stripped  till  the  pelvic  brim  is 
reached  and  the  bifurcation  of  the  common  iliac  artery  found  where  the 
ureter  crosses  it  (this  incision  also  serves  to  explore  the  lower  ureter).  Having 
freed  the  vessel,  it  is  secured  with  a  rubber-covered  intestinal  clamp.  This 
proceeding  takes  but  a  few  minutes  and  does  not  increase  the  shock  appre- 
ciably, while  it  cuts  off  all  blood-supply  except  the  anastomosis  via  the 
epigastric  vessels.  Methods  of  tying  the  common  femoral  artery  early 
do  not  affect  the  sciatic  and  gluteal  vessels,  which  may  cause  much  haemor- 
rhage when  divided. 

Many  plans  of  dividing  the  soft  tissues  have  been  devised,  but  the 
external  racket  incision  is  the  simplest,  and  by  this  method  the  muscles  are 
most  easily  cleared  from  the  great  trochanter. 

Having  temporarily  secured  the  common  iliac,  a  longitudinal  incision 
is  carried  down  to  the  bone  from  two  inches  above  the  great  trochanter  to 
about  five  inches  below  on  the  external  surface  of  the  limb.  From  the  lower 
end  of  the  longitudinal  incision  a  circular  cut  is  made  round  the  limb, 
cutting  skin  and  superficial  fascia  only ;  these  are  allowed  to  retract  and 
the  muscles  divided  with  a  second  circular  cut  down  to  the  bone.  The 
upper  end  of  the  femur  is  then  cleared,  keeping  close  to  the  bone,  dividing 
the  muscles  attached  to  the  trochanters  till  the  capsule  is  found  and  opened, 
the  head  dislocated,  and  the  remaining  structures  divided  by  passing  the 
knife  down  the  deep  surface  of  the  femur,  when  the  amputation  is  complete. 
The  superficial  and  deep  femoral,  sciatic  arteries  and  descending  branches 
of  the  external  circumflex  are  found  and  tied ;  the  sciatic  and  anterior 
crural  nerves  dissected  up  some  inches  and  cut  across.  The  temporary 
clamp  is  removed  from  the  common  iliac  and  any  bleeding- points  picked 
up  and  tied.  Loss  of  blood  will  be  trifling.  The  abdominal  wound  and 
the  amputation  flaps  are  sutured  in  the  usual  way,  the  latter  being  drained 
for  twenty- four  hours. 

Furneaux  Jordan's  method  is  simple  and  effective.  A  tourniquet  is 
placed  high  up  the  thigh  and  a  high  circular  amputation  of  the  thigh  carried 
out.  The  vessels  are  tied  and  the  tourniquet  removed.  Next  a  lateral 
incision  down  to  the  bone  is  carried  up  from  the  circular,  one  to  two  inches 
above  the  great  trochanter  and  the  upper  end  of  the  bone  enucleated.  This 
plan  is  simple  and  has  the  advantage  that  if  there  is  much  shock  from  the 
preliminary  circular  amputation  enucleation  of  the  upper  end  of  the  bone 
may  be  carried  out  a  few  days  later.  If  excision  has  already  been  performed 
the  enucleation  of  the  upper  end  of  the  femur  becomes  a  very  trifling  affair. 
The  flaps  made  by  the  Furneaux  Jordan  method  are  long,  which  is  good 
in  most  insances,  but  where  (as  for  malignant  growths)  these  are  to  be  cut 
as  high  as  possible  the  first  method  will  prove  more  expeditious. 

The  anterior  racket  method  in  which  the  vessels  are  tied  as  met  with,  is  not 


THE  FEMUR.    OSTEOMYELITIS.    TUMOURS  513 

recommended,  as  it  is  very  easy  to  tie  the  superficial  femoral  artery,  mis- 
taking it  for  the  common  trunk,  and  have  severe  bleeding  when  the  deep 
branch  is  divided  later  in  the  operation.  Also  it  is  much  less  easy  to  clear 
the  muscles  from  the  great  trochanter  by  this  method. 

Affectioxs  of  the  Femur,  (a)  Acute  Pyogenic  Infections.  Those  of 
the  upper  end  have  already  been  described  with  the  hip- joint,  but  acute 
diaphysitis  is  more  common  at  the  lower  end,  and  often  a  very  serious  menace 
to  life.  In  the  early  stages  this  affection  may  be  mistaken  for  acute  rheu- 
matism, but  rigors,  delirium,  and  tenderness  of  the  lower  end  of  the  bone, 
even  without  swelling,  indicate  that  exploratory  operation  is  essential : 
later,  where  the  periosteum  is  stripped  by  subjacent  pus  there  will  be  well- 
marked  swelling  of  the  lower  end  of  the  bone  ;  the  pus  may  travel  into  the 
popliteal  space,  occasionally  into  the  knee-joint. 

Treatment.  The  bone  should  be  exposed  on  its  outer  side  and  freely 
opened  by  a  long  gutter  and  lightly  packed  with  gauze.  Tubes  in  the 
popliteal  region  are  to  be  avoided,  as  they  will  surely  erode  the  popliteal 
artery.  If  signs  of  infection  persist  after  this  treatment  the  diaphysis  of 
the  femur  should  be  removed,  or  in  severe  cases  amputation  of  the  thigh 
performed.  In  really  severe  cases  there  should  be  very  little  delay  before 
employing  these  more  drastic  measures,  as  fatal  general  infection  may  follow 
at  any  time. 

(b)  Subacute  and  chronic  infection  with  pyogenic  organisms  or  the 
tubercle  bacillus  also  occur  here,  while  chronic  hyperostosis  in  tertiary 
syphilis  is  found  more  often  in  this  bone  than  elsewhere  except  the  tibia. 

(c)  Tumours  of  the  Femur.  (1)  The  lower  end  of  the  femur  is  a  common 
site  for  exostoses  which  tend  to  become  pedunculated  and  point  away  from 
the  knee-joint.  They  originate  near  the  epiphyseal  line  but  are  left  behind 
by  the  growth  of  the  bone,  so  that  after  some  years  they  may  be  a  little 
distance  away,  in  the  lower  third  of  the  femur. 

(2)  The  lower  end  of  the  femur  is  one  of  the  sites  for  myeloid  sarcoma. 
In  the  early  stages  the  diagnosis  may  be  difficult,  since  slight  pain  will  be 
the  only  sign  except  the  appearance  under  X-rays.  Hence  the  importance 
of  this  method  of  investigation  for  slight  and  obscure  affections  about  the 
knee.  Later,  when  the  bone  is  distended  and  softened  areas  are  present, 
it  may  be  confused  with  tuberculous  disease,  but  the  site  of  main  swelling 
is  the  lower  end  of  the  femur  and  not  the  joint,  while  the  movements  of 
the  latter  are  preserved  for  a  considerable  time  :  again,  in  doubtful  cases 
radiography  will  render  diagnosis  assured. 

Treatment.  In  the  early  stages  erasion  of  the  tumour,  cauterizing  the 
wall  with  pure  carbolic,  and  inserting  some  form  of  bone-stopping,  will 
effect  a  cure.  If  the  bone  is  badly  destroyed  and  will  collapse  if  scraped  out, 
it  should  be  resected  and  its  place  supplied  either  by  grafting  or  allow in<_r 
the  limb  to  shorten  and  using  a  high  boot. 

(3)  Periosteal  sarcoma  of  the  femur  is  extremely  malignant,  and  it  is 
very  doubtful  if  amputation  at  the  hip-joint  ever  preserves  life  or  even 
prolongs  it  very  much. 

1  K 


514  A  TEXTBOOK  OF  SURGERY 

Diagnosis.  The  appearance  of  a  rapidly  growing  swelling  of  the  bone, 
usually  more  od  one  aspect,  sharply  rising  from  the  surface  and  painless 
at  first,  will  help  to  separate  from  inflammatory  swelling  or  myeloid  growth  ; 
the  radiographic  appearance  shows  its  periosteal  origin  clearly. 

Treatment.  Unless  causing  much  pain  and  disability  by  its  size  and 
extension,  one  would  rather  hesitate  about  advising  amputation  at  the 
hip  as  a  curative  measure  as  long  as  the  patient  can  use  the  limb,  though 
as  palliative  treatment  it  may  be  worth  while  if  nerves  are  badly  involved 
and  is  certainly  preferrable  to  a  long  course  of  morphia  with  all  its  attendant 
honors.     The  field  is  open  here  for  radiotherapy. 

(i)  Metastatic  tumours  (usually  carcinomas)  may  cause  spontaneous 
fracture  of  the  femur.  Their  practical  import  is  in  the  recognition  that 
they  are  not  primary,  and  so  avoiding  the  performance  of  a  useless  amputa- 
tion. The  treatment  is  as  for  other  fractures.  Union  may  take  place, 
but  it  is  unlikely  that  the  patient  will  be  able  to  use  the  limb  again — which 
renders  amputation  in  such  cases  a  less  serious  error  than  it  otherwise 
would  be. 

(5)  Simple  cysts  (osteitis  fibrosa)  occur  in  the  femur,  though  less  often 
than  in  the  humerus. 

Amputation  through  the  Thigh.  Indications.  Severe  injuries  of  the 
limb,  rapidly  spreading  infections,  gangrene  of  the  foot  in  middle-aged 
and  old  persons,  malignant  disease  of  the  leg  or  knee,  advanced  tuberculosis 
of  the  knee,  especially  in  more  elderly  patients. 

The  bone  should  be  divided,  if  possible,  not  above  the  middle  third 
of  its  length,  since  a  short  stump  will  be  of  little  use  in  controlling  the 
movements  of  an  artificial  leg  and  does  not  allow  of  such  a  wide  removal 
of  disease  as  disarticulation  at  the  hip-joint,  while  the  shock  is  not  so  very 
much  less  than  in  amputation  at  the  latter  situation. 

Operation.  With  the  patient  in  the  dorsal  position  the  limb  is  over  the 
edge  of  the  table  and  a  tourniquet  is  applied  at  the  upper  end  of  the  thigh. 
Flaps  are  cut  according  to  the  state  of  the  soft  tissues.  A  long  anterior 
and  short  posterior  flap  are  made  or  a  circular  amputation  modified  by 
lateral  incisions  to  allow  of  more  easy  retraction  of  the  soft  parts,  and, 
resulting  in  equal  antero-posterior  flaps,  will  give  equally  good  result  pro- 
vided the  flaps  are  long  enough,  i.e.  the  flaps  together  should  be  equal  in 
length  to  twice  the  diameter  of  the  limb  at  the  point  where  the  bone  is 
to  be  divided.  In  making  the  anterior  flap  the  skin  and  superficial  fascia 
should  alone  be  divided  and  these  parts  allowed  to  retract  before  the  muscles 
are  cut,  while  in  the  posterior  part  the  hamstrings  retract  so  readily  that 
they  may  be  divided  in  one  incision  with  the  skin.  The  vessels  to  be  tied 
are  the  superficial  and  deep  femorals  and  descending  branches  of  the  external 
circumflex.  The  sciatic  nerve  must  be  dissected  out  and  divided  high  up. 
The  artificial  limb  for  this  amputation  will  take  its  bearing  from  the  tuber 
ischii. 


INFLAMMATIONS  OF  THE  KNEE-JOINT  515 

THE   REGION  OF  THE  KNEE 

In  this  section  are  described  congenital  defects,  inflammations,  defor- 
mities, and  disease  of  bursse. 

(a)  Congenital  Defects.  Dislocation  of  the  knee-joint  is  a  rare 
congenital  condition  sometimes  associated  with  absence  of  the  patella. 
When  the  child  is  old  enough  to  walk,  a  walking  instrument  should  be  worn 
to  control  the  movements  of  the  joint,  and  especially  to  prevent  hyper- 
extension,  which  is  a  likely  accompaniment  of  this  deformity.  Dislocation 
of  the  patella  and  genu  recurvatum  may  be  due  to  congenital  or  acquired 
causes,  and  will  be  mentioned  again  under  Deformities. 

(b)  Inflammations.  Infections,  and  Degenerations.  (1)  Acute  in- 
fections may  happen  in  the  course  of  general  infections  of  pyaeniic  nature, 
by  direct  spread  of  infection  from  surrounding  bone  or  bursa?  or  from 
puncture-wounds.  Gonorrhceal  and  pneumococcal  infections  are  fairly 
common,  especially  the  former,  while  rheumatism  is  of  frequent  occurrence. 

Diagnosis.  In  acute  inflammation  of  the  knee-joint,  whether  simple  or 
suppurative,  the  joint  is  slightly  flexed  to  allow  of  full  distension  of  the 
synovial  cavity,  and  the  outlines  of  this  above  and  to  the  side  of  the  patella, 
with  fluctuation  and  "  patella  tapping  "  (performed  by  forcing  back  the 
patella,  which  is  floated  up  by  the  effusion,  till  it  raps  against  the  anterior 
surface  of  the  femur)  will  point  to  effusion  in  t|ie  joint.  Severe  inflammation 
and  suppuration  are  indicated  by  the  skin  over  the  joint  changing  from  red 
to  purple  and  becoming  oedematous,  by  high  irregular  fever,  rigors,  and  a 
pronounced  leucocytosis,  but  in  any  doubtful  case  the  joint  should  be 
aspirated  early  on  one  side  of  the  patella  and  the  fluid  examined  bacterio- 
logically. 

Treatment.  In  the  milder  cases  rest  on  a  back-splint  with  a  foot-piece, 
the  knee  being  slightly  flexed,  will  suffice.  Where  suppuration  or  severe 
infection  is  present  the  joint  should  be  opened  on  either  side  of  the  patella, 
washed  out  with  dilute  solution  of  biniodide  of  mercury  (1  in  2000),  and 
drained ;  the  washing  may  be  repeated.  If  this  is  insufficient  the  joint 
should  be  laid  open  widely  from  in  front,  dividing  the  patella  rather  than 
cutting  through  ligaments.  It  is  sometimes  advised  to  drain  the  posterior 
pouches  of  the  joint  by  cutting  down  on  the  posterior  surfaces  of  the  condyles 
behind,  but  in  practice  this  plan  does  not  give  satisfactory  drainage.  In 
more  severe  infections,  or  where  the  above  measures  are  insufficient,  excision 
of  the  joint  or  amputation  may  be  needed.  Should  the  condition  subside 
early  under  drainage  and  the  cartilages  remain  unaffected,  passive  move- 
ments should  be  commenced  early,  since  by  this  means  a  movable  joint 
may  result  even  after  suppuration. 

(2)  Tuberculosis  of  the  Knee-joint.  This  disease  is  particularly 
common  in  children  and  young*  persons,  but  also  occurs  at  much  later 
periods  of  life. 

The  infection  may  originate  in  either  the  ends  of  the  bones  or  in  the  synovial 
membrane,     The  morbid  anatomy  is  similar  to  that  of  other  joints  but  with 


516  A  TEXTBOOK  01  SURGERY 

more  tendency  to  massive  necrosis  and  formation  of  sequestra  than  is  usually 
the  ease.  When  commencing  in  the  bones  the  inner  side  of  the  femur  or 
tibia  is  most  often  affected.  The  granulation-tissue  destroys  the  cartilages 
and  ankylosis  will  usually  result,  or  tuberculous  osteomyelitis  may  spread 
a  long  way  up  the  shafts  of  the  bones  while  the  joint  is  badly  disorganized. 

When  the  synovial  membrane  is  the  starting-point  two  types  are  noted  : 
(a)  the  hydropic  ;    (6)  the  ulcerative  with  fibrosis  and  "  white  swelling." 

(a)  The  type  with  large  effusion  (hydrops)  is  usually  found  in  adults, 
and  is  of  mild  nature  in  its  initial  stages,  the  joint  becoming  slowly  distended 
with  fluid.  The  synovial  membrane  is  but  slightly  thickened  and  covered 
with  grey  tubercles  :  melon-seed  bodies  and  fibrinous  coagula  are  found  in 
the  otherwise  clear  exudate. 

Clinically,  there  is  little  pain  but  a  feeling  of  weakness  of  the  joint. 
the  movements  of  which  are  but  little  impaired.  The  joint  is  found  to  be 
filled  with  fluid,  distension  of  the  synovial  membrane  and  the  supra- 
patellar pouch  are  obvious,  and  fluctuation  and  "  patella-rapping  "  are 
obtained. 

Diagnosis.  The  condition  resembles  other  forms  of  hydrarthrosis, 
traumatic,  gonorrhceal,  syphilitic,  osteo-arthritic,  neuropathic,  &c. ;  and 
the  diagnosis  is  made  partly  by  exclusion,  but  in  some  cases  not  till  the 
joint  is  aspirated  or  opened  and  some  of  the  synovial  membrane  examined 
microscopically,  as  the  fluid  often  appears  sterile  unless  injected  into  guinea- 
pigs. 

The  prognosis  is  tolerably  good  if  treated  by  rest,  elastic  pressure  (strap- 
ping), with  the  foot  off  the  ground  ;  but  if  neglected  the  disease  may  invade 
bone,  destroy  cartilages,  and  assume  the  characters  of  the  ulcerative  type. 

Occasionally  in  this  type  there  is  less  effusion  and  more  proliferation 
of  the  fringes,  which  form  fibrous  and  polypoid  masses,  tending  to  cause 
"  locking  "  of  the  joint  and  closely  resembling  the  changes  found  in  osteo- 
arthritis. 

(6)  The  type  with  ulceration  is  more  common  and  usually  found  in 
children.  The  synovial  membrane  is  much  thickened  and  there  is  little 
effusion.  The  thickening  of  the  synovial  membrane  is  made  of  granulation- 
tissue,  which  invades  cartilage  and  bones.  If  the  resistance  of  the  patient 
is  good  the  result  will  be  a  formation  of  reparative  fibrous  tissue  in  and 
about  the  joint,  leading  to  ankylosis,  without  much  destruction.  Where 
the  infection  proceeds  more  vigorously  there  will  be  caseation,  abscess-forma- 
tion, and  considerable  destruction  of  bone  with  the  appearance  of  sinuses, 
and  should  healing  result  there  will  be  much  deformity  and  shortening, 
while  operative  treatment,  possibly  ending  in  amputation,  may  be  necessary. 

Signs.  Clinically,  joints  of  this  type  are  examples  of  the  classic  "  white 
swelling."  At  first  the  patient  complains  of  pain  and  limping,  and  on 
examination  the  joint  is  found  to  be  fixed  in  a  slightly  flexed  position,  while 
there  is  a  doughy  swelling  of  the  synovial  membrane,  but  no  fluid  can  be 
detected  in  the  joint.  As  the  disease  progresses  the  swelling  becomes  more 
marked,  especially  as  the  muscles  above  and  below  waste,  so  that  the  joint 


TUBERCULOSIS  OF  THE  KNEE 


517 


appears  as  a  spindle-shaped  swelling  in  the  atrophic  limb.  The  joint  becomes 
more  flexed  till  it  may  be  at  a  right  angle.  In  addition  the  tibia  becomes 
displaced  backwards  on  the  femur,  the  condyles  of  which  project  markedly 
in  front  of  the  anterior  surface  of  the  tibia,  owing  to  the  softening  of  the 
ligaments  and  constant  spasm  of  the  hamstrings  :  also  the  leg  is  rotated 
outward  by  the  more  powerful  biceps.  These  three  displacements  (signs 
of  disorganization  of  the  ligamentous  structures  of  joint) — flexion,  backward 
displacement,  and  external  rotation  of  the  tibia — are  known  as  the  "  triple 


1 


1 


Fig.  209.     Backward  displacement  of  the  tibia  in  old-standing  arthritis  of  the  knee 
(usually  tuberculous).     I,  Normal.     II,  Displaced  backward. 


displacement,"  and  are  especially  noted  in  tuberculosis  of  the  knee.  Later, 
abscesses  form  and  burst  about  the  joint,  leaving  sinuses. 

Diagnosis.  From  gummatous  synovitis  the  more  nodular  character 
of  the  infiltration  in  the  latter,  as  well  as  the  slight  pain  and  impairment  of 
movement  and  the  serum-reaction,  will  distinguish. 

Hsemophilic  joints  may  resemble  those  due  to  tuberculosis,  but  the 
rapid  onset  with  effusion  of  blood,  distending  the  joint-cavity,  and  the  family 
and  personal  history  will  help  in  differentiating.  From  myeloid  and  other 
sarcomas  in  the  early  stages  X-rays  are  most  valuable,  since  clinical  exami- 
nation may  reveal  so  little  in  either  case,  but  greater  fixity  and  pain  will 
suggest  tuberculosis. 


518 


\  TKXTBOOK  OK  SIHCKHV 


Where  tin'  disease  takes  origin  in  the  ends  of  the  bones  it  may  come  to 
the  surface  outside  the  joint,  forming  ;i  cold  abscess,  the  joint  possibly 
escaping.  When  the  spread  is  through  the  articular  cartilage  into  the 
joint,  the  signs  will  resemble  those  of  the  "  white  swelling  "  type  with  slow- 
onset,  but  occasionally  there  may  be  a  rapid  effusion  into  the  joint  and 
formation  of  tuberculous  pus,  distending  the  synovial  cavity  (empyema). 

In  the  initial  stages,  before  the  cavity  of  the 
joint  is  affected,  signs  will  be  slight,  usually 
only  pain  and  limping,  the  joint  movements 
being  practically  not  affected,  and  diagnosis  from 
new  growth  hardly  possible  without  the  help  of 
radiographs,  when  the  ossifying  trabeculae  in  the 
growth,  or  the  laminated  subperiosteal  new  bone 
in  the  case  of  infective  disease,  will  help  in 
forming  an  opinion.  Tuberculosis  is,  of  course, 
enormously  more  common  than  new  growth,  and 
for  this  reason  the  latter  is  often  missed  in  the 
early  stages,  from  the  habit  of  regarding  all 
affections  of  joints  in  young  persons  as  tuber- 
culous and  not  confirming  with  radiograms. 

Treatment.  Conservative  measures  will 
suffice  for  most  cases,  especially  in  children  and 
in  the  type  with  effusion  found  in  adults.  This 
implies  rest  of  the  joint  in  an  almost  extended 
position  and  saving  the  joint  from  jarring  by 
keeping  the  foot  off  the  ground.  Where  the 
joint  is  flexed  it  must  be  extended  gradually  by 
placing  the  patient  on  the  back  with  the  thigh 
suitably  flexed  and  exercising  weight-extension 
in  the  axis  of  the  tibia,  on  a  graduated  splint 
which  can  be  lowered  every  second  or  third  day 
till  the  knee  is  very  nearly  straight ;  this  can 
usually  be  managed  in  about  ten  days.  If  there 
is  a  tendency  for  flexion  to  recur,  the  limb  must 
be  placed  in  plaster  from  hip  to  ankle.  The 
foot  is  kept  off  the  ground  by  wearing  a 
Thomas's  knee-splint  with  a  patten  on  the 
sound  foot  and  using  crutches.  Every  effort  should  be  made  to  improve 
the  general  condition  by  good  food  and  outdoor  life.  The  splint  should 
be  worn  for  a  year  or  more  and  at  least  six  months  after  all  signs  of  active 
disease  have  disappeared,  such  as  puffmess,  pain,  tenderness,  starting  at 
night,  &c. 

The  use  of  the  limb  should  be  renewed  very  gradually.  Abscesses  are 
t  reated  on  general  principles. 

Operative  Treatment.  Indications.  In  children  when,  in  spite  of  con- 
servative  measures  effectively  carried  out,  after  some  months  the  disease 


li'..  210.     Thomas's  knee- 
splint. 


TREATMENT  OF  TUBERCULOSIS  OF  THE  KNEE   510 


is  still  advancing,  as  shown  by  greater  swelling,  formation  of  sinuses,  pro- 
gressive invasion  of  bones  as  seen  in  radiographs.  In  adults  operation 
should  be  undertaken  earlier  than  in  children  and  as  soon  as  it  is  clear  that 
the  articular  cartilages  are  destroyed,  since  the  course  of  the  disease  will  be 
shortened  by  operation  and  in  any  case  of  this  degree  ankylosis  is  certain, 
while  there  is  not  the  same  risk  of  causing  shortening 
of  the  limb,  as  in  children,  from  damage  to  the 
epiphysis.  The  type  of  operation  varies  with  the 
condition  present,  formal  excision  being  rarely  done  ; 
arthrectomy  is  the  rational  procedure,  removing  only 
diseased  tissues,  but  these  very  thoroughly ;  where 
only  synovial  membrane  is  involved  it  alone  is  re- 
moved, but  if  the  bones  are  much  affected  the  opera- 
tion may  be  practically  an  excision.  Operation  should 
not  be  delayed  in  adults  where  the  disease  is  advancing. 
since  the  outlook  for  excision  is  bad  in  advanced 
cases  and  secondary  amputation  may  be  needed. 
Another  reason  for  operative  treatment  is  a  faulty 
position  of  the  limb,  which  is  not  amenable  to  correc- 
tion by  extension.  In  such  cases  a  combination  of 
arthrectomy  with  cuneiform  osteotomy  will  be  needed 
to  straighten  the  limb  and  remove  diseased  tissues. 
Where  healing  has  taken  place  in  bad  position  (usually 
flexion)  a  cuneiform  osteotomy  will  be  needed  to  pro- 
duce a  straight  limb.  Finally,  where  there  is  great 
disorganization  of  the  joint  with  severe  hectic  fever 
or  lardaceous  disease,  or  where  excision  has  failed, 
amputation  through  the  thigh  will  be  the  last 
resource. 

(3)  Osteo-arthritis,  often  the  result  of    injury, 


is 


Fig.  211.     A,  Pattern  to 
common  in  the  knee-joint,     lhe  recurrent  errusions,  gt  a  foot  0f  soun(i  side 

lipping  of  the  bones,  grating,  and  deformity  render  witn    Thomas's  *  splint. 

-.f1      &  .  »   &  &'  J  B>  xhomas's  knee-splint 

diagnosis  easy.  with  foot-piece. 

Treatment  is  on  the  general  lines  for  this  affection. 
Operative  measures  are  advisable  where  loose  bodies  form  in  the  fringes  and 
break  off  and  cause  locking  or  other  trouble  (joint-mice).  Such  loose  bodies 
or  inconvenient  fringes  may  be  removed  after  opening  the  joint.  W  here 
the  joint  is  dry  and  the  cartilages  eroded  lubrication  of  the  joint  by  inject- 
ing vaseline  (Rovsing)  has  met  with  some  success.  Occasionally  excision 
is  indicated  where  one  side  only  is  affected  and  pain  and  disability  are  great. 

(4)  Neuropithic  disease  (Charcot)  is  common  in  the  knee-joint.  The 
sudden  onset  with  effusion,  the  rapid  progress  with  great  destruction  of 
bone,  softening  of  ligaments,  abnormal  mobility  and  much  deformity, 
together  with  signs  of  tabes,  render  diagnosis  easy. 

Treatment  consists  in  protecting  the  joint  and  making  it  as  strong  as 
possible  by  some  appliance  to  assist  in  walking,  since  if  much  strain  is 


\  TEXTBOOK  OF  SURGERY 

thrown  on  the  other  limb  neuropathic  changes  will  shortly  occur  in  the 
joints  of  that  as  well.  The  application  of  a  Thomas's  Calliper  knee-splint 
ami  crutches  will  enable  the  patient  to  get  about  for  some  considerable  time. 

(c)  Deformities  about  the  Knee-joint.  (1)  Dislocations  of  the 
Patella.  This  usually  takes  place  outwards  and  may  be  constant  or  occa- 
sional— in  the  latter  case  occurring  when  the  knee  is  bent  and  throwing 
the  patient  down,  causing  great  pain  and  effusion  into  the  joint.  In  either 
form  the  patella  rests  on  the  external  condyle.  The  condition  may  be 
congenital  from  laxity  of  the  ligaments  of  the  capsule  and  deficient  develop- 
ment of  the  external  condyle,  or  associated  with  genu  valgum,  when  it 
arises  from  the  altered  direction  of  the  pull  of  the  quadriceps  on  the  patella, 
the  latter  being  dragged  outwards  as  well  as  upwards. 

Treatment  consists  in  correction  of  bony  deformity  in  the  axis  of  the  joint, 
such  as  is  due  to  genu  valgum,  and  shortening  the  lax  internal  part  of  the 
capsule  by  dividing  it  longitudinally  and  suturing  with  free  overlapping 
of  the  portions. 

(2)  Genu  Recurvation  or  IIi/per-extensio7i  of  the  Knee.  This  may  be  due 
to  various  causes  : 

(a)  Arising  as  a  congenital  deformity,  probably  from  faulty  position 
in  utero,  sometimes  associated  with  absence  of  the  patella  or  other  deformity. 

Trent im  nt.  The  joint  is  flexed  to  a  right  angle  under  anaesthesia  if 
need  be,  and  retained  in  plaster  till  the  deformity  does  not  recur. 

(b)  Occasionally  from  rickety  curves  of  the  femur  or  tibia,  when  it  will 
be  corrected  by  splints  or  osteotomy,  according  to  its  degree  of  severity. 

(c)  As  a  result  of  anterior  poliomyelitis  of  the  quadriceps  femoris  and 
hamstrings,  in  which  case  the  knee  is  flail-like.  The  result  of  standing  on 
the  limb  tends  to  cause  hyper-extension,  which  is  useful  in  minor  degrees, 
causing  a  more  secure  locking  of  the  extended  joint,  but  if  becoming  exagge- 
rated will  need  correction  by  the  use  of  a  walking  appliance  with  a  stop  to 
prevent  hyper- extension  and  a  movable  lock  to  allow  the  knee  being  bent 
while  sitting. 

(3)  Contracture  or  Flexion  of  the  Knee,  (a)  This  may  arise  from  fibrous 
or  osseous  ankylosis  consecutive  to  disease  of  the  joint,  in  which  case  a 
(unciform  osteotomy  will  be  needed  to  restore  the  limb  to  an  almost  extended 
position,  after  which  a  poroplastic  splint  with  steel  support  should  be  worn 
for  some  years  or  the  deformity  will  certainly  recur. 

(b)  In  other  instances  the  contracture  may  be  the  result  of  spastic 
paralysis.  In  such  cases  the  tendons  of  the  hamstrings  should  be  lengthened, 
and  in  severe  cases  the  biceps  may  be  transplanted  into  the  patella  to  act 
as  an  extensor. 

(1)  Flail  Knee.  This  is  the  result  of  infantile  paralysis  of  the  quadriceps 
and  hamstrings,  and  leads  to  difficulty  in  walking;  if  the  limb  cannot  be 
jerked  forward  into  the  hyper-extended  position  but  is  placed  on  the  ground 
slightly  flexed,  the  knee  gives  way  and  the  patient  falls  to  the  ground. 
I  his  difficulty  can  be  obviated  by  wearing  an  instrument  to  maintain 
extension   of  the   limb   while  walking  but  allowing  flexion   when  seated. 


GENU  VALGUM  AND  VARUM 


521 


Another  plan  is  to  perform  arthrodesis  of  the  knee,  which  consists  in  opening 
the  joint,  removing  articular  cartilage  from  the  femur  and  tibia,  and  allowing 
ankylosis  to  take  place  in  the  best  position. 

Where  the  quadriceps  alone  is  paralysed  so  that  the  imperfectly  extended 
knee  tends  to  collapse  when  the  patient  stands  on  the  limb,  the  sartorius 
may  be  grafted  into  the  patella  or  the  biceps  may  be  used,  otherwise  a 
walking  instrument  will  be  needed 
as  in  the  last-mentioned  condi- 
tion. 

(5)  Genu  Valgum  and  Varum. 
(a)  Genu  Valgum  or  Knock-knee. 
Normally,  when  standing  with  the 
legs  extended  and  the  internal 
malleoli  and  inner  borders  of  the 
feet  touching  each  other  the  in- 
ternal condyles  of  the  femur  will 
be  separated  by  about  half  an 
inch.  If  when  standing  in  this 
position  the  condyles  touch  each 
other  the  condition  is  one  of  genu 
valgum  ;  if  they  are  separated  by 
more  than  one  inch  the  condition 
is  that  of  genu  varum.  Such 
minor  degrees  of  either  genu  val- 
gum or  varum  may  be  present, 
especially  the  latter,  without  in- 
terfering with  the  strength  or 
activity  of  the  patient. 

In  more  severe  cases  of  genu 
valgum  the  malleoli  will  not 
touch  while  the  legs  are  extended 
at  the  knee,  the  condyles  com- 
ing in  contact  first  and  prevent- 
ing this.  The  cause  of  genu 
valgum  is  most  commonly  an 
unequal  growth  of  the  two  sides 
of  the  lower  part  of  the  diaphysis 
of    the    femur,    the    outer    part 

growing  slowly,  the  inner  more  rapidly,  so  that  the  internal  condyle 
is  lower  than  the  outer,  causing  the  leg  to  deviate  outward  at  the 
knee  ;  in  some  cases  there  is  curvature  of  the  bones  as  well  (usually  from 
rickets).  The  usually  accepted  explanation  of  these  differences  in  growth, 
is  that  the  deformity  is  due  to  prolonged  standing  in  faulty  positions  with 
the  knee  thrust  inward,  which  stretches  the  internal  lateral  ligament  and 
compresses  the  external  condyle.  The  latter  undergoes  pressure  atrophy, 
or  rather  insufficient  growth,  while  the  internal  condyle  grows  in  excess 


Fig.  212.     Marked  genu  valgum  on  the  right 

side  combined  with  moderate  genu  varum  of 

the  left  knee. 


\  TEXTBOOK  OF  SURGERY 

to  till  in  the  gap  caused  by  the  stretching  of  the  internal  lateral  ligament. 
As  for  practical  purposes  growth  takes  place  entirely  from  the  diaphyseal 
side  ol  the  epiphyseal  line,  it  follows  that  the  inner  side  of  the  femoral 
diaphvsis  is  overlong  and  the  epiphyseal  line,  instead  of  being  horizontal, 
inclines  downwards  at  its  inner  end — which  is  an  important  fact  in  the 
operative  treatment.  The  causes  of  softening  of  the  bones  which  permit 
of  this  deformity  taking  place  are  the  softening  of  bones  found  in  adolescents, 
or  in  small  children  rickets  (there  is  more  curvature  in  these  cases). 

Acute  and  chronic  inflammations  and  accidents  account  for  a  small 
number  of  cases. 

Signs.  In  slight  eases  which  are  yet  severe  enough  to  produce  functional 
defect,  there  will  be  noted  weakness  of  the  legs,  which  become  easily  tired, 
a  shambling  and  ungainly  walk,  often  with  splaying  out  of  the  feet  (flat- 
foot  is  a  common  complication).  When  a  more  severe  degree  is  present  the 
knees  actually  knock  together  and  must  be  circumducted  round  each  other 
tn  avoid  this,  and  the  lower  limbs  resemble  the  letter  X  when  viewed  from 
front  or  back.     The  biceps  and  ilio-tibial  band  are  shortened. 

To  examine  for  Knock-knee.  The  patient  is  seated,  the  bared  legs 
completely  extended  at  the  knee,  and  attempt  made  to  bring  together  the 
internal  malleoli  and  inner  borders  of  the  feet.  It  will  be  found  that  the 
malleoli  are  prevented  from  touching  in  this  position  by  the  previous  coming 
together  of  the  internal  condyles ;  the  separation  of  the  malleoli  will  vary 
from  one  to  twelve  inches  or  more,  and  note  is  made  whether  one  or  both 
limbs  are  affected.  Care  must  be  taken  that  the  knees  are  fully  extended 
in  making  this  test,  as  the  deformity  disappears  with  flexion  of  the  knees 
and  the  malleoli  can  be  made  to  touch  in  even  severe  cases  of  genu  valgum. 

(b)  In  genu  varum  (bow-leg)  the  deformity  is  more  often  due  to  curvature 
from  rickets  than  to  the  bone-softening  of  adolescents.  The  curvature 
affects  both  femur  and  tibia? ;  sometimes  the  tibiae  are  more  affected  (see 
Curved  Tibia?).  The  result  is  a  bowing-out  of  the  lower  limbs  at  the  knee  ; 
in  severe  cases  the  legs  present  the  appearance  of  an  0  when  seen  from  front 
or  back.  The  effect  on  walking  is  much  less  than  that  of  genu  valgum, 
many  good  athletes  being  decidedly  bow-legged,  but  where  the  limbs  are 
approaching  the  letter  0  in  shape,  progression  will  be  slow.  Examination 
is  made  as  for  genu  valgum  with  the  legs  extended  at  the  knee  ;  when  the 
malleoli  are  touching  there  will  be  an  interval  of  over  an  inch  between  the 
condyles. 

Treatment.  For  genu  valgum  in  infants  up  to  three  years  the  simplest 
plan  is  to  encase  the  limb  in  Gooch's  splinting  from  the  groin  to  below  the 
feet,  the  inside  being  well  padded  with  wool  and  the  splint  being  cut  out 
in  front  to  take  the  foot  and  so  prevent  rotation  of  the  splint,  while  the 
projection  below  the  feet  prevents  the  patient  walking  ;  the  splint  encircles 
about  half  the  circumference  of  the  limb.  These  splints  should  be  changed 
night  and  morning  and  the  limb  well  massaged.  These  simple  splints  keep 
in  position  well  and  are  very  effective,  and  may  be  worn  for  six  to  twelve 
i iionths.     After  four  years  operative  measures  may  be  needed  in  the  more 


TREATMENT  OF  GENU  VALGUM 


523 


severe  cases  if  the  deformity  is  over  four  inches  (Tubby).  Operative  measures 
are  also  advisable  in  considerably  younger  patients  where  the  deformity 
is  very  severe,  e.g.  if  the  patient  is  between  two  and  three  with  a  separation 
of  the  malleoli  of  over  twelve  inches.  In  less  severe  cases  from  four  to  eight, 
splints  may  be  continued,  and  for  this  the  simple  plan  advised  above  may 
be  continued  or  an  apparatus  may  be  made  by  an  instrument-maker  con- 
sisting of  an  external  iron  the  length  of  the  leg  with  pelvic  band  and  foot 
attachment  to  prevent  slipping,  while  a  well-padded  strap  over  the  knee 
can  be  tightened  and  pulls  the  knee  out  to  the  normal  position.  Such 
instruments  are  useless  if 
jointed  at  the  knee,  and  there- 
fore if  efficient  are  incon- 
venient for  walking.  Hence 
in  most  cases  which  cause  dis- 
ability in  older  children  opera- 
tive treatment  is  advisable, 
when  osteotomy  of  the  femur 
just  above  the  internal  con- 
dyle after  Macewen's  method 
is  most  suitable. 

For  genu  varum  treatment 
is  less  often  needed,  but  where 
due  to  curving  of  the  tibiae, 
in  small  children  osteoclasis 
(manual)  is  indicated  if  splint- 
treatment  is  insufficient.  Os- 
teoclasis about  the  knee-joint 
by  powerful  osteoclasts  is  inad- 
missible :  where  the  bone  is  to 
be  broken  it  should  be  done 
cleanly  with  an  osteotome. 
The  main  consideration  in  the 
operative  treatment    of   these 

deformities  is  to  divide  the  bones  as  close  as  possible  to  the  main  seat 
of  deformity.  For  this  reason  in  the  adolescent  type,  where  the  chief 
trouble  is  at  the  lower  end  of  the  diaphysis  of  the  femur,  Macewen's 
osteotomy  is  admirably  suited  ;  but  where  there  are  curves  in  the  shafts 
of  the  femur  or  tibia  the  bone  affected  should  be  divided  at  the  apex  of 
the  main  curvature,  and  in  bad  cases  both  femur  and  tibia  may  need 
division. 

Occasionally  there  may  be  genu  valgum  on  one  side  and  genu  varum 
on  the  other,  resulting  in  a  bowing  of  both  legs  in  one  direction.  Treatment 
is  as  described  above. 

(d)  Bursal  Affections  about  the  Knee-joint.  There  are  a  large 
number  of  bursa?  in  this  situation  but  only  a  few  are  of  surgical  importance. 

(1)  The  prepatellar  bursas,  or  bursee  situated  in  front  of  the  patella  and 


Fig.    213.      Application    of    a    splint   of   Gooch's 

material  for  genu  valgum  or  curved  tibiae  in  small 

children. 


V'l  A  TEXTBOOK  OK  SlTH(JKHY 

ligamentum  patellae,  become  inflamed  by  repeated  injuries,  as  in  kneeling 
(house  ma  id's  knee) ;  the  inflammation  may  subside  or  become  chronic 
with  much  thickening  of  the  wall  of  the  bursa,  or  suppuration  may  result. 
Where  the  irritation  is  continued  chronic  changes  or  suppuration  are  almost 
certain  to  ensue. 

The  simple  and  chronic  inflammation  can  hardly  be  mistaken  for  any- 
thing else,  but  the  suppurative  variety  when  spreading  widely  may  cause 
cellulitis  of  surrounding  parts  (a  not  infrequent  complication),  and  is  to  be 
distinguished  from  acute  arthritis  of  the  knee-joint  by  the  freedom  from 
swelling  of  the  suprapatellar  pouch  and  the  fact  that  the  movements  of 
the  joint  are  but  little  affected. 

Treatment.  The  simple  acute-  cases  can  be  temporarily  relieved  by 
tapping  followed  by  firm  pressure,  but,  unless  the  occupation  is  altered, 
will  recur  and  become  chronic.  When  the  condition  is  chronic  and  fibrous 
the  bursa  should  be  dissected  out.  In  acute  suppuration  free  incision  and 
drainage  are  needed. 

(2)  The  bursa  over  the  front  of  the  tubercle  of  the  tibia  sometimes 
undergoes  chronic  inflammation  :  its  superficial  position  renders  recognition 
easy,  and  it  should  be  dissected  out. 

(3)  The  bursa  under  the  ligamentum  patellae  (subligamentous  bursa) 
is  fairly  often  affected  and  requires  some  care  to  locate ;  the  knee  appears 
puffy  but  the  suprapatellar  pouch  is  free,  the  swelling  being  below  the 
patella,  and  passive  movements  are  painless  except  that  of  extreme  flexion, 
when  the  inflamed  bursa  is  jammed  beneath  the  tense  ligamentum  patellae, 
and  fluctuation  is  more  obvious  on  the  affected  side  than  on  the  other. 
(Note. — Fluctuation  is  normally  present  to  some  degree  in  this  situation 
owing  to  the  pad  of  fat  there  present.)  These  bursae  may  become  chroni- 
cally thickened  and  even  calcified. 

Titatment.  The  simple,  acute  cases  may  be  cured  by  rest,  but  if  the 
trouble  persists  the  bursa  should  be  dissected  out  through  an  incision  at 
one  side  of  the  ligamentum  patellae,  when  it  will  often  be  found  more 
thickened  than  might  be  expected  from  superficial  examination. 

(•4)  The  bursa  at  the  insertion  of  the  sartorius  and  semi-tendinosus 
occasionally  becomes  inflamed  from  strains,  but  more  often  from  the  growth 
of  an  exostosis  underneath.  A  radiograph  will  disclose  the  latter  condition 
when  there  is  any  doubt ;  and  its  early  removal  will  cure  the  bursitis. 

(5)  The  bursa  over  the  head  of  the  fibula  between  the  tendon  of  the 
biceps  and  the  external  lateral  ligament  also  is  sometimes  inflamed  ;  if  not 
subsiding  on  rest  and  strapping,  it  should  be  excised. 

(6)  At  the  back  of  the  joint  the  most  important  bursa  is  that  between 
the  gastrocnemius  and  semi-membranosus  tendon  to  the  inner  side  of  the 
popliteal  space,  which  is  often  inflamed  and  distended  and  may  sometimes 
communicate  with  the  joint.  This  is  to  be  distinguished  from  popliteal 
aneurysm  by  the  position  on  the  inner  side  of  the  popliteal  space  and  the 
absence  of  pulsation  ;  from  inflamed  popliteal  glands  by  the  position,  the 
much  smaller  amount  of  pain,  and  by  the  fact  that  there  is  but  little  flexion 


ARTHROTOMY  OF  THE  KXEE 


525 


of  the  knee,  which  is  a  constant  feature  of  suppuration  of  the  popliteal 
glands. 

Treatment.  These  inflammations  usually  subside  on  rest  and  pressure  by 
means  of  strapping,  but  may  take  some  time  to  do  so  ;  where  they  persist, 
removal  by  dissection  is  needed.     Suppuration  in  this  situation  is  rare. 

When  associated  with  tuberculosis  or  rheumatoid  arthritis  of  the  knee 
these  bursse  may  spread  down  amongst  the  calf-muscles  and  are  known  as 
Baker's  cysts  ;  in  such  cases  they  should  be  removed 
by  dissection. 

Operations  on  the  Knee-joint.  (1)  Aspiration 
of  this  joint  can  be  readily  performed  on  either  side 
of  the  patella,  whether  for  exploration  (this  should  be 
frequently  done  in  acute  conditions)  or  for  injecting 
substances  such  as  vaseline  for  lubrication  of  rheuma- 
toid joints  (Rovsing)  or  antiseptics  such  as  2  per  cent, 
formalin  in  glycerin  (Murphy)  or  iodoform  emulsion. 

(2)  Arthrotomy  is  also  done  by  incision  on  either 
side  of  the  patella,  and  suffices  for  drainage  but 
allows  only  a  slight  exploration  of  the  joint. 

The  method  of  approaching  the  semilunar  cartilages 
is  described  under  Injuries  about  the  Knee  (p.  332). 

(3)  Arthrectomy  and  Excision  of  the  Knee.  Modern 
operations  tend  more  and  more  to  the  type  of  arthrec- 
tomy which  implies  removal  of  diseased  tissues  only. 
The  more  classic  excision,  in  which  bone  was  invariably 
removed  and  synovial  membrane  perhaps  left  is  out 
of  place,  though  an  arthrectomy  may  be  as  extensive 
as  an  excision  as  far  as  the  bones  are  concerned.     One  FlG 

of  the  troubles  after  the  operation,  when  otherwise  sue-  knee  by  external  j-inci- 

<•  i    •     •  ■        a      ■  ,i      i  ji  -,  •      sion.      The   dotted  line 

cesslul,  is  increasing  flexion  at  the  knee,  and  hence  it  is  s\xows    the    temporary 

important  to  preserve  the  extensor  apparatus  as  far  as  displacement  of  the  tu- 
...  .....         ...  ..       .    .    ,        ml  bercle  of  the  tibia  with 

possible,  while  giving  full  access  to  the  joint,     there     the  patellar  ligament, 
are  two  methods  by  which  this  may  be  managed. 

(a)  A  flap  may  be  turned  up  in  front  with  its  apex  one  inch  below  the 
patella,  its  base  at  the  condyles  ;  the  patella  is  cut  across  with  the  saw. 
or  in  children  with  the  knife,  giving  free  exposure  of  the  joint,  the  bone  being 
wired  at  the  end  of  the  operation. 

(b)  In  Kocher's  method  a  J -shaped  incision  is  made,  starting  four  inches 
above  the  outer  border  of  the  patella,  passing  an  inch  outside  the  patella, 
and  ending  at  the  tubercle  of  the  tibia.  The  tubercle  of  the  tibia  is  cut 
away  with  chisel  from  the  shaft  and  carries  with  it  the  ligamentum  patellae, 
and  is  fixed  in  position  at  the  end  of  the  operation  with  screw  or  peg.  The 
ligamentum  patella?  should  never  be  divided,  as  union  is  bad  here,  and 
there  should  always  be  an  incision  well  up  on  one  side  of  the  joint  to  expose 
the  suprapatellar  pouch.  The  interior  of  the  joint  being  well  exposed  by 
one  of  these  incisions,  the  diseased  synovial  membrane  is  carefully  removed 


A  TEXTBOOK  OF  si'KUERY 


by  dissection.  The  articular  cartilage  and  crucial  ligaments  will  probably  need 
removal  as  well,  but  in  some  cases  may  be  spared,  though  it  is  hardly  possible 
to  clear  the  posterior  ligament  properly  without  dividing  the  crucials  first. 
Usually  foci  of  disease  will  need  gouging  out  from  the  bones.  In  some  cases 
the  patella  will  need  removal,  and  for  this  reason  the  second  method  has 
the  advantage.  Where  the  disease  is  advancing  the  ends  of  the  tibia  and 
femur  must  be  sawn  ofi  as  in  excision,  but  the  epiphyseal  line  should  be 
respected  in  young  subjects,  i.e.  the  saw-cut  should  be  below  the  adductor 
tubercle  in  the  femur  and  above  the  insertion  of  the  semi-membranosus  in 


'  I 


\ 


A  B 

Fig.  215.  A,  Ankylosis  of  knee  with  severe  angular  deformity  following  pyogenic 
disease.  (From  a  skiagram.)  B,  The  same  knee  after  cuneiform  osteotomy  or 
excision  of  the  knee,  showing  method  of  maintaining  a  position  with  a  temporary 

steel  peg. 

the  tibia  unless  there  is  gross  spread  of  disease  to  these  parts,  when  the 
epiphyses  will  necessarily  be  sacrificed.  The  sawr-cuts  should  be  made  so 
that  when  the  ends  are  in  apposition  the  knee  is  not  quite  extended.  Where 
bone  or  cartilage  is  removed  there  will  be  no  hope  of  a  movable  joint,  but 
if  the  synovial  membrane  alone  is  removed  some  movement  will  probably 
follow.  Where  ankylosis  is  to  be  expected,  as  is  usually  the  case,  the  bones 
may  be  fixed  in  position  by  driving  a  steel  needle  or  French  nail  obliquely 
from  the  upper  end  of  the  tibia  into  the  femur,  leaving  the  end  projecting 
so  that  it  may  be  removed  in  about  a  month.  A  tourniquet  is  advisable 
for  this  operation  and  drainage  for  two  days  after.  The  limb  is  placed  on 
a  back-splint  for  two  to  three  weeks  till  healed,  and  the  foot  kept  off  the 
ground  for  four  to  six  months,  when  the  joint  should  be  soundly  healed  in 
favourable  cases. 


CUNEIFORM  AND  MACEWEN'S  OSTEOTOMY  OF  THE  KNEE    527 


The  indications  for  this  operation  are  tuberculosis,  especially  in  adults, 
when  not  improving  in  a  few  months  on  splinting  ;  for  infective  arthritis 
as  a  secondary  operation  where  there  is  much  destruction  of  bone  ;  for 
ankylosis  in  bad  position  and  in  case  of  flail-knee  from  infantile  paralysis 
(in  such  cases  called  arthrodesis). 

In  cases  of  old,  healed  tubercle  with  ankylosis  in  a  bad  position  (severe 
flexion)  the  operation  is  directed  rather  to  the  bone  than  the  synovial 
membrane,  the  latter  being  healed  in  these 
cases.  A  flap  is  turned  up,  the  patella  cut 
through,  and  a  wedge  of  bone  removed, 
including  the  lower  end  of  the  femur  and 
upper  end  of  the  tibia,  the  apex  of  the  wedge 
pointing  backwards  so  that  the  knee  can  be 
brought  into  the  almost  extended  position. 

After  all  excisions  at  the  knee  an  appa- 
ratus should  be  worn  for  three  to  four  years 
to  keep  the  limb  extended,  or  flexion  will 
take  place  although  the  union  is  firm  and 
bony. 

(4)  Osteotomy  for  Deformities  about  the 
Knee.  The  bones  may  be  divided  from  the 
inner  or  outer  side.  In  the  cases  usually 
met  with  (genu  valgum  of  adolescents)  the 
deformity  is  chiefly  at  the  lower  end  of  the 
femoral  diaphysis,  and  hence  division  from 
the  inner  side  by  Macewen's  method  gets 
nearest  to  the  deformity  and  gives  the  best 
results. 

Operation.  The  limb  is  everted  and  placed 
with  the  outer  side  of  the  femur  snugly  rest- 
ing on  a  sand-bag.  A  point  is  selected  half 
an  inch  in  front  of  the  adductor  tubercle  (to 
avoid  the  anastomotic  artery)  and  half  an 
inch  above  the  external  condyle  which  marks 
the  upper  limit  of  the  epiphyseal  line,  thus 
avoiding  injury  of  this  important  structure 
in  subsequent  bone-section.  Through  a  half- 
inch  longitudinal  incision  at  this  point,  the 
osteotome  is  introduced  and  rotated  so  that  its  edge  is  across  the  length 
of  the  bone,  which  is  then  cut  across  by  blows  of  the  mallet.  The  inner, 
posterior  and  anterior  dense  portions  of  the  bone  are  gradually  cut 
through,  marking  progress  by  feeling  with  the  end  of  the  osteotome.  "When 
these  parts  are  well  divided  the  bone  may  be  broken  by  moderate  force 
applied  in  the  direction  of  abduction.  Great  force  should  not  be  employed 
but  rather  longer  use  of  the  osteotome,  or  the  joint  may  be  injured.  The 
limb  is  placed  on   a  long   splint    fully   corrected   for   fourteen   days   and 


2  1 

Fig.     216.        Genu    valgum. 

A,  Through  the  epiphyseal 
line   and    adductor   tubercle. 

B,  Line  of  osteotomy  to 
avoid  A.  Alterations  in  the 
alignment  of  the  knee-joint. 
1,  Normal.     2,  Genu  valgum. 


A  TEXTBOOK  OK  Sl'HOKHY 

then  in  a  long  plaster-spica  for  about  six  weeks,  after  which  walking  and 
movements  are  gradually  instituted. 

In  cases  due  to  rickets  where  the  deformity  is  rather  a  bending  of  the 
femur  or  the  tibia  or  both,  one  or  other  or  both  bones  (in  severe  cases)  may 
be  divided  in  a  similar  manner — the  femur  from  the  outer,  the  tibia  from 
the  inner  side  ;  in  very  severe  deformity  a  wedge  of  bone  may  be  removed. 

Osteotomies  involving  the  joint  such  as  those  of  Reeves  or  Ogston, 
are  to  be  avoided  as  certain  to  be  detrimental  to  that  important  structure. 

(5)  Tenotomy  and  lengthening  of  the  hamstrings  are  done  as  open  opera- 
tions, the  Z  method  being  that  of  choice.  Transplantation  of  the  sartorius 
or  biceps  into  the  patella  is  readily  done  by  raising  a  flap  of  sufficient  extent 
to  include  both  insertions. 

(6)  Amputations  about  the  Knee.  The  limb  may  be  removed  through 
the  knee-joint,  which  has  the  advantage  of  providing  a  long  stump  able 
to  bear  a  good  deal  of  pressure  on  its  face  but  rather  long  to  permit  of  the 
adaptation  of  an  artificial  knee-joint.  Where  the  amputation  must  be 
above  the  joint  the  patella  should,  if  possible,  be  spared  and  used  to  form 
the  face  of  the  stump,  as  in  Stokes's  or  Gritti's  operation,  since  this  bone 
with  the  skin  over  it  will  bear  considerable  pressure.  Where  the  patella 
is  unavoidably  removed  the  skin  over  it  will  be  much  weakened  and  pressure 
here  will  be  poorly  borne ;  therefore  amputation  through  the  condyles 
without  the  patellar-facing,  as  in  Carden's  method,  has  little  to  commend 
it.  and  the  section  may  as  well  be  in  the  lower  third  of  the  femur,  the  arti- 
ficial limb  taking  its  bearing  from  the  tuber  ischii. 

Formerly  amputations  below  the  knee  were  done  about  four  inches 
below  the  joint  at  what  was  known  as  the  "  seat  of  election,"  because  the 
artificial  limbs  then  employed  took  the  knee  in  the  flexed  position  and  a 
long  stump  projecting  backward  was  only  in  the  way.  With  advances 
in  the  making  of  artificial  limbs  the  long  stump  can  be  utilized  for  taking 
the  latter  and  the  knee  is  able  to  perform  its  normal  functions,  so  that 
amputation  at  the  seat  of  election  is  practically  obsolete,  since  the  stump 
is  too  short  to  permit  of  using  an  instrument  attached  entirely  below  the 
knee,  while  the  length  of  the  stump  prevents  the  use  of  an  artificial  knee- 
joint  in  the  walking  apparatus.  On  the  whole,  then,  for  amputation  at 
the  joint  a  supracondylar  method  with  preservation  of  the  patella  is  best 
if  the  patient's  condition  is  sufficiently  good  to  ensure  union  of  the  bones, 
otherwise  the  amputation  should  be  through  the  joint.  Where  amputation 
is  done  below  the  knee  it  should  be  as  far  down  as  possible  to  secure  a  good 
stump  for  the  artificial  limb. 

(a)  Amputation  above  the  Knee-joint  (supracondylar  method  of  Stokes). 
A  U-shaped  flap  is  cut  on  the  anterior  aspect  of  the  limb,  the  base  being 
one  inch  above  the  condyles,  the  apex  level  with  the  tubercle  of  the  tibia. 
The  ligamentum  patellae  is  divided  and  the  joint  opened  ;  the  flap,  including 
the  patella  and  other  structures  down  to  the  bone,  is  raised.  The  posterior 
flap  is  then  cut  nearly  as  long  as  the  anterior  (length  is  important  here 
owing  to  the  great  retraction  of  the  hamstrings)  and  down  to  the  bone, 


STOKES'S  AXD  STEPHEN  SMITH'S  AMPUTATIONS       529 


which  is  cleared  of  soft  parts  to  an  inch  and  a  half  above  the  articular 

surface,  i.e.  distinctly  above  the  condyles.     The  femur  is  sawn  through  in 

this  situation  and  the  cartilaginous  surface  removed  from  the  patella  with 

the  saw.     The  vessels  to  be  tied  are  the  popliteal  and  articular  branches  ; 

the  popliteal  nerves  are  resected  high  up,  and  the  rawed*  patella  fixed  over 

the  lower  end  of  the  femur  with  a  deep  suture. 

The  suture-line,  which  is  horizontal,  is  drawn  to 

the  back  of  the  stump  by  the  retraction  of  the 

hamstrings,  the    face    of    the    stump   being  well 

covered.      In    Gritti's    operation    the    femur    is 

divided  through  the  widest  part  of  the  condyles 

(transcondylar),   but   the   larger   surface    of    the 

femur  does  not  tit  the  patella  so  well  as  in  the 

method    of   Stokes    and    the    greater   length    of 

the  femur  renders  the  patella  more  inclined  to 

become  tilted  by  tension  of  the  quadriceps. 

(b)  Amputation  through  the  knee-joint  is  con- 
veniently done  by  the  method  of  lateral  flaps 
(Stephen  Smith).  Well-rounded  flaps  are  made, 
starting  from  the  lowest  part  of  the  tubercle  of 
the  tibia,  extending  two  inches  below  this  point, 
and  ending  at  the  back  on  a  level  with  the  articu- 
lation, i.e.  they  slope  up  at  the  back.  The  skin 
and  subcutaneous  tissues  are  peeled  ofE  the  bone 
till  the  joint  is  reached,  the  ligamentum  patellae 
divided,  and  the  joint  opened  below  the  semilunar 
cartilages,  which  are  separated  from  the  tibia  and 
reflected  with  the  flaps.  The  lateral,  crucial,  and 
posterior  ligaments  are  divided,  and  cutting 
through  the   gastrocnemii   and    popliteal    vessels 

completes  the  amputation.  The  vessels  require  ligature  as  before.  The 
suture-line  is  in  an  antero-posterior  direction  and  the  cicatrix  falls  into  the 
intercondvlar  notch. 


Fig.  217.  Amputations 
through  the  lower  end  of 
the  femur;  skin  incision 
and  bone  section,  e,  Gritti  s 
amputation  (transcondy- 
lar), c,  Stokes's  amputation 
(supracondylar).  d,  Line 
for  removal  of  cartilagi- 
nous surface  of  patella. 


THE  BONES  OF  THE  LEG 

(a)  Acute  Infections.  Both  bones,  but  especially  the  tibia,  are  prone 
to  acute  infective  diaphysitis.  The  upper  end  of  the  tibia  is  one  of  the 
commonest  places  for  this  disease  in  the  body,  and  owing  to  its  superficial 
position  is  as  a  rule  easily  diagnosed,  except  in  early  cases  where  the  infec- 
tion is  spreading  down  the  interior  of  the  bone  rather  than  subperiosteally. 
The  importance  of  early  exploration  of  the  bone  in  such  cases  has  already 
been  insisted  on.  The  tibia  is  well  suited  for  diaphysectomy  in  cases  where 
chiselling  a  wide  gutter  down  the  bone  does  not  suffice  to  cut  short  infection, 
since  the  bone  is  superficial  and  the  presence  of  the  fibula  prevents  the 
occurrence  of  shortening. 

(b)  Subacute  pyogenic   infection   leading  to   chronic   abscess  (Brodie) 
i  34 


530  A  TEXTBOOK  OF  SURGERY 

occurs  at  either  end  of  this  bone.     Treatment  by  drainage,  bone-stopping, 
&c.,  have  been  already  described. 

(<■)  Tuberculosis  of  the  tibia  usually  results  by  a  spread  from  infection 
of  the  ankle  or  knee,  and  implies  the  need  of  a  wide  resection  of  bone  in 
operations  on  theSe  joints. 

((/)  Syphilis  in  the  form  of  nodes  in  the  secondary  stage  is  common, 
while  gummata  along  the  shin  are  very  common  in  tertiary  syphilis  but 
comparatively  seldom  affect  the  bone.  The  most  characteristic  lesion  of 
the  bone  due  to  syphilis  occurs  in  the  congenital  form,  where  there  is  an 
increased  production  of  dense  bone,  chiefly  along  the  front  of  the  tibia, 
with  some  bending  of  the  bone  (scabbard  tibia).  This  condition  is  seldom 
seen  before  six  years  of  age,  and  the  slight  curve  involving  the  whole  length 
of  the  bone  in  a  strictly  antero-posterior  plane  and  the  thickened  blunt, 
anterior  edge  of  the  bone  felt  through  the  skin  all  help  to  distinguish  the 
condition  from  curvatures  due  to  rickets.  The  condition  may  be  painful 
but  subsides  slowly  under  antisyphilitic  treatment  (Figs.  156,  157). 

(e)  Rickety  curvature  of  the  tibia  is  extremely  common,  and  usually 
consists  in  a  bending  out  and  forward  of  the  lower  half  of  the  bone  ;  some- 
times the  whole  bone  curves  outward  and,  especially  if  combined  with 
outward  bowing  of  the  femur,  will  give  rise  to  the  deformity  genu  varum. 
Occurring  in  small  children  one  and  a  half  to  four  years  of  age,  the  outward 
curving,  often  at  a  sharp  angle,  and  the  other  signs  of  rickets — square  head, 
beaded  ribs,  pigeon-chest,  thick  ankles  and  wrists — readily  distinguish  from 
the  slight  general  curve  of  congenital  syphilis. 

Treatment.  The  general  and  dietetic  measures  in  rickets  are  described 
in  the  section  on  bone  disease  in  general.  Under  three  years  of  age  splinting 
the  limb  so  as  to  prevent  any  weight  coming  on  the  foot  will  cure  in  most 
cases.  The  splints  of  Gooch's  material  advocated  for  genu  valgum  serve 
here  also.  Six  months  in  the  splints  are  advisable,  and  it  is  important  that 
no  weight  should  be  taken  on  the  limb.  Where  the  curve  is  severe  in 
children  over  three  years  of  age,  or  where  improvement  on  splinting  alone 
is  not  adequate,  it  will  be  best  to  break  the  bone  at  the  point  of  greatest 
curvature.  Over  six  years  of  age  this  should  be  done  (unless  the  surgeon 
is  phenomenally  strong  and  heavy)  by  osteotomy;  under  six  manual 
osteoclasis  gives  very  good  results. 

Manual  osteoclasis  is  performed  by  padding  the  limb  well,  with  wool 
bandaged  over  it,  and  placing  with  the  point  of  maximum  convexity  on  the 
apex  of  a  rubber-covered  wedge  and  then  bearing  with  the  hands  forcibly, 
as  close  as  possible  to  the  site  of  intended  fracture  to  avoid  injuring  the 
epiphyses.  Where  fracture  does  not  take  place  readily  it  is  better  to  proceed 
to  osteotomy,  either  linear  or  cuneiform,  rather  than  to  risk  injuring  the 
limb  elsewhere  or  rupturing  the  surgeon. 

(/)  The  tibia,  and  especially  its  upper  end,  is  a  favourite  place  for  the 
growth  of  myeloid  sarcoma.  In  the  later  stages  a  tumour  rising  abruptly 
and  bursting  forward  from  the  upper  end  of  the  bone  with  areas  of  fluctua- 
tion, sometimes  pulsation,  and  over  which  distended  veins  are  noted,  is 


AMPUTATION  THROUGH  THE  LEG 


531 


the  usual  condition.  Whether  any  of  these  tumours  are  really  aneurysms 
by  anastomosis  (cirsoid  aneurysms)  is  uncertain  in  most  cases ;  probably 
degeneration  in  myeloid  growth  accounts  for  such  appearances.  In  the 
early  stages  diagnosis  apart  from  radiograms  is  often  impossible,  and  even 
then  they  may  be  confused  with  simple  cysts  till  exploration  is  made. 

Treatment.  Erasion  and  bone-filling  in  the  earlier  cases,  resection  and 
bone-grafting  in  those  more  advanced,  or  possibly  allowing  the  ends  of  the 
bone  to  come  together  with  a  shortened  leg,  since  bone-grafting  does  not 
always  fulfil  its  promise  where  much  strength  is  needed,  as  in  the  leg.     Ampu- 


Fig.  218.     Periosteal  sarcoma  of  the  upper  end  of  the  tibia  (a  piece  was  removed 
for  section) ;  the  swelling  involves  the  outer  external  part  of  the  bone. 


tation  has  often  been  done  and  will  surely  cure  the  condition,  but  is  seldom, 
if  ever,  necessary. 

(g)  Periosteal  sarcomas  are  also  found  growing  from  the  tibia  ;  ampu- 
tation through  the  femur  may  cure,  though  this  is  unlikely. 

Operations  on  the  Leg.  Resection  of  bone,  diaphysectomy,  and  osteo- 
tomy are  frequently  performed  on  the  tibia,  but  are  similar  to  these  opera- 
tions elsewhere  and  need  no  further  description. 

Amputation  through  the  Leg.  Indications.  Severe  smashes  of  the 
foot  and  ankle  too  high  for  some  of  the  excellent  operations  at  the  ankle 
to  be  done,  advanced  tuberculosis  of  the  ankle,  malignant  growths  of 
the  ankle  or  foot.  Seldom,  if  ever,  for  gangrene  of  the  foot,  as  in  such  cases 
amputation  through  the  lower  thigh  is  safer. 

As  already  mentioned,  section  of  the  bones  at  the  "  seat  of  election  " 
is  no  longer  profitable  and  may  be  considered  obsolete.  The  stump  should 
be  as  long  as  possible,  and  the  most  generally  useful  method  is  by  equal, 
lateral,  hooded  flaps  (Jacobson).     Selecting  a  point  an  inch  below  the  place 


532 


A  TEXTBOOK  OF  S TRUER Y 


of  intended  section  of  the  bone,  lateral  U-shaped  flaps  are  cut  in  length 
equal  to  the  diameter  of  the  limb  at  the  point  of  division  of  the  bone.  The 
flaps  contain  skin,  superficial  and  dec])  Eascise,  and  are  retracted  up  to  the 
line  of  bone-section  ;  the  muscles  are  then  divided  by  a  circular  incision 
and  the  bone  divided,  cutting  the  anterior,  sharp  edge  of  the  tibia  away 
obliquely  or  it  will  press  on  the  scar  and  perhaps 
protrude.  The  hooded  junction  of  the  flaps  in 
front  should  cover  well  over  the  projection  of  the 
tibia.  The  method  by  a  single  long  external  flap 
of  Farabceuf  or  the  longer  anterior  flap  of  Teale 
have  nothing  to  recommend  them  except  variety 
in  a  class  of  operative  surgery  on  the  cadaver. 

THE   REGION  OF  THE   ANKLE 

(a)  Acute  inflammations  of  the  ankle-joint  arise 
from  injuries,  punctured  wounds,  by  spread  from 
acute  osteitis  of  the  neighbouring  bones,  or  by 
metastasis  in  such  diseases  as  pyaemia,  gonorrhoea, 
&c. — the  ankle  being  frequently  affected  in  the 
latter  disease.  When  filled  with  effusion  the  joint 
becomes  partly  extended  (plantar-wards)  and  the 
effusion  produces  a  swelling  on  either  side  of  the 
extensor  tendons  in  front  and  of  the  tendo  Achillis 
behind,  in  either  of  which  situations  the  joint 
may  be  aspirated  or  opened  for  drainage. 

Treatment.     In  the  milder  cases  rest  on  a  back- 
splint  with  a  foot-piece  and  aspiration.     Drainage 
and  irrigation  for  more  severe  infections,  vaccines 
for   gonorrhceal    infection.      In    very   severe    infections   removal    of    the 
astragalus  (see  Excision)  will  secure  better  drainage  ;    eventually  ampu- 
tation may  be  needed. 

(b)  Tuberculosis  of  the  Ankle-joint.  This  occurs  usually  in  children 
and  young  adults,  and  most  often  commences  in  the  synovial  membrane  ; 
if  of  osseous  origin  the  astragalus  *s  the  most  common  starting-point. 

Signs.  After  preliminary  pain  and  limping  the  joint  presents  the 
characters  of  "  white  swelling,"  most  marked  on  either  side  of  the  extensor 
tendons  and  the  tendo  Achillis.  The  foot  is  in  a  position  of  partial  plantar- 
flexion,  movements  are  limited  and  painful,  the  calf-muscles  are  notably 
wasted.     Later  sinuses  appear  in  front  and  behind  the  joint. 

Where  the  origin  is  osseous  pain  and  limping  are  noted,  but  radiographs 
are  needed  to  show  local  disease  in  the  early  stages.  The  abscesses  resulting 
may  track  along  the  peroneal  and  posterior  tibial  sheaths. 

Diagnosis.  From  chronic  inflammation  and  tuberculosis  of  the  bursa? 
and  tendon-sheaths  of  this  region,  which  are  common,  the  swelling — limited 
to  these  structures  and  generally  on  one  aspect  only  of  the  joint,  the  move- 
ment of  the  joint  being  less  affected  and  the  disability  in  walking  much 


Fig.    219.       Amputation 
through  the  leg  by  equal 
lateral   flaps ;    skin   inci- 
sion and  bone-section. 


OPERATIONS  OX  THE  ANKLE  533 

less — will  distinguish.  Where  the  os  calcis  or  tarsal  bones  are  affected  the 
swelling  is  lower  and  the  ankle  movements  are  normal,  while  in  chronic 
abscess  of  the  lower  end  of  the  tibia  the  swelling  is  above  the  joint  and  the 
movements  of  the  latter  little  affected.  In  all  these  cases  radiographs  are 
most  helpful  for  accurate  localization  of  disease. 

Treatment.  The  foot  should  be  put  up  in  a  plaster-case,  care  being 
taken  that  it  is  at  right  angles  with  the  leg,  and  no  weight  should  be  taken 
on  the  affected  limb,  either  by  slinging  the  foot  or  using  a  Thomas's  knee- 
splint  and  patten  on  the  other  foot.  The  plaster  should  be  removed  at 
least  once  a  month  at  first,  in  case  a  cold  abscess  forms.  The  plaster  will 
need  to  be  employed  for  at  least  a  year.  Where  sinuses  and  abscesses  form 
they  are  treated  as  usual.  Where  the  disease  progresses,  especially  in 
adults,  excision  of  the  joint  should  be  performed  ;  and  if  this  fails,  amputa- 
tion above  the  malleoli  or  Mickulicz's  complete  tarsectomy,  leaving  the 
metatarsus  in  the  equinus  position.  This  last  operation  is  useful  where 
the  heel  is  much  affected  and  there  is  no  chance  of  making  a  posterior  flap 
as  is  needed  in  Syme's  amputation  (Fig.  220). 

(c)  Rheumatoid  and  neuropathic  changes  are  found  in  this  joint,  the  former 
not  very  often,  though  the  ankle  is  a  fairly  common  place  for  a  Charcot's 
joint  to  develop.  In  the  later  case  relief  may  be  obtained  by  the  use  of  a 
Thomas's  calliper  knee-splint  to  take  the  weight  of  the  ankle  ;  failing  this, 
Syme's  amputation  may  be  thought  necessary. 

Operations  about  the  Ankle-joint.  (1)  Arthrectomi) .  Typical  exci- 
sion is  seldom  performed  owing  to  the  weakness  of  the  resulting  ankle  ;  the 
more  usual  operation  is  removal  of  the  astragalus  and  synovial  membrane. 

Indications  are  severe  tuberculosis,  pyogenic  infection  and  unreduced 
dislocation  of  the  astragalus. 

The  best  exposure  is  by  the  external  incision  of  Kocher.  This  starts 
four  inches  above  the  tip  of  the  external  malleolus,  passing  down  between 
the  latter  and  the  tendo  Achillis,  then  round  the  malleolus,  and  ending 
over  the  base  of  the  fifth  metatarsal.  The  peroneal  tendons  are  divided 
at  the  upper  part  of  the  incision,  the  external  lateral  ligament  divided,  and 
the  joint  opened  from  the  outer  side.  The  tendons  of  the  extensors  and 
peronei  are  separated  subperiosteally  and  the  foot  dislocated  inwards  so 
that  the  sole  looks  upwards.  This  admits  of  a  good  inspection  of  the  joint. 
The  astragalus  may  be  removed  partially  or  completely  ;  all  diseased  bone, 
synovial  membrane,  and  tendon-sheaths  are  dissected  away.  The  tendons 
and  ligaments  are  sutured  and  the  skin  closed.  As  soon  as  the  wound  is 
healed  the  foot  is  placed  in  plaster  in  good  position  (at  right-angles). 

(2)  Total  Tarsectonnj  (Mickulicz).  This  is  a  resection  of  the  posterior 
part  of  the  foot,  useful  in  cases  where  the  disease  is  spreading  to  the  os  calcis 
and  tarsal  bones.  A  transverse  incision  is  carried  across  the  back  of  the 
foot  between  the  malleoli  and  another  across  the  sole  of  the  foot  between 
the  tubercle  of  the  scaphoid  and  the  base  of  the  fifth  metatarsal  bone.  These 
are  joined  by  lateral  incisions  and  the  extensor-tendons  and  dorsalis-pedis 
artery  are  raised  off  the  dorsum  of  the  tarsus  (special  care  being  taken  of 


:>3f 


A  TEXTBOOK  OF  SURGERY 


the  artery  which  carries  the  blood-supply  of  the  distal  portion).  The  posterior 
incision  is  tarried  down  to  the  bones,  which  are  sawn  through  above  the 
malleoli.  The  loose  part,  consisting  of  lower  end  of  tibia  and  fibula,  os  calcis, 
astragalus  cuboid  and  cuneiform,  is  dissected  from  the  dorsal  flap  which 
carries  the  vessels,  and  the  bases  of  the  metatarsals  sawn  through.     After 

ligature  of  vessels  (posterior 
tibial)  the  metatarsals  are 
brought  into  line  with  the 
tibia  and  fixed  to  its  end 
with  a  few  periosteal 
sutures  in  a  position  of 
equinus.  Later,  when 
healed,  the  patient  walks 
on  tip-toe  with  a  useful 
springy  stump  (Fig.  220). 

Amputations  about 
the  Ankle.  This  is  one 
of  the  few  situations  where 
a  stump  can  be  made  which 
will  readily  take  the  weight 
of  the  body  on  its  face,  the 
covering  being  made  of  the 
tough  skin  and  superficial 
fascia  of  the  heel.  There 
are  three  methods  avail- 
able— all  admirable  but 
suited  to  different  condi- 
tions. 

(1)  Symes  Amputation 
(modified).  Transmalleolar 
amputation  with  heel-flap. 
Sitting  down,  the  surgeon 
makes  an  incision  across 
the  sole  of  the  foot  from 
the  tip  of  the  external 
to  half  an  inch  below  the  internal  malleolus,  dividing  everything  down  to 
the  os  calcis  ;  the  incision  slopes  slightly  back  to  the  heel. 

Next  the  surgeon,  standing  up,  makes  a  second  incision  on  the  dorsal 
surface  over  the  head  of  the  astragalus,  dividing  everything  down  to  this 
and  joining  the  extremities  of  the  first  incision.  This  short  anterior  flap 
is  dissected  up  and  the  ankle-joint  opened  (it  will  be  remembered  that  this 
joint  lies  half  an  inch  above  the  tip  of  the  internal  malleolus  and  thus 
avoid  opening  the  astragalo-scaphoid  joint).  Forcibly  plantar-flexing  the 
foot,  the  knife  is  thrust  into  the  ankle-joint  and  the  lateral  ligaments  are 
divided  from  within  outwards,  twisting  the  foot  to  the  opposite  side  to 
the  ligament  to  be  divided.     The  posterior  ligament  is  divided  and  the 


Fig.  220. 


Result  of  complete  tarsectomy  (Mickulicz) 
on  the  right  foot. 


SYME'S  AND  PIEOGOFF'S  AMPUTATIONS 


535 


upper  surface  of  the  os  calcis  bared.  Now,  keeping  very  close  to  the  bone 
and  strongly  flexing  the  foot  in  the  plantar  direction  so  that  the  sole  finally 
looks  upwards,  the  os  calcis  is  dissected  out  of  the  heel-flap  till  the  first 
incision  is  encountered,  when  the  astragalus  and  foot  are  removed.  A 
strong,  short-bladed  knife  with  long  handle  (Syme's  knife)  is  useful  for 
this  operation,  and  the  modern  method,  as  described,  is  far  more  expeditious 
than  the  original  plan  of  Syme,  who  laboriously  scraped  the  heel-flap  off 
the  os  calcis  with  thumb-nail  and  knife.  The  amputation  is  completed 
by  retracting  the  short  anterior  and  the  heel-flap  and  sawing  through  the 


PRESSURE 


Fig.  221.     Amputation  about  the  ankle,  showing  skin  incisions  and  line  of  section 

of  bone.     I,  Syme's.     II,  Pirogoff  s ;  both  modified,  showing  the  point  of  pressure 

when  the  flaps  are  adjusted. 


malleoli  shortly  above  the  ankle-joint.  The  flap  is  sutured  transversely  : 
drainage  may  be  made  through  a  small  puncture  in  the  back  of  the  heel- 
flap. 

(2)  Pirogoff 's  Amputation  (modified).  Transmalleolar  with  osteoplastic 
section  of  the  os  calcis. 

The  incisions  start  from  the  same  points  as  in  the  former  operation,  but 
the  plantar  incision  slopes  forward  to  give  more  covering  to  the  larger 
stump.  The  operation  proceeds  as  before,  cutting  the  heel-flap  to  the 
bone,  opening  the  ankle-joint  from  the  dorsum,  and  cutting  the  lateral 
and  posterior  ligaments  of  the  ankle,  when,  instead  of  clearing  the  os  calcis, 
the  latter  is  sawn  through  obliquely  downward  and  forward  in  line  with 
the  plantar  incision,  thus  removing  the  foot,  and  the  tibia  and  fibula  are 
also  sawn  obliquely,  more  being  removed  from  the  posterior  than  the 
anterior  side  of  the  bones,  and  the  portion  of  os  calcis  remaining  fits  on  to 
the  lower  end  of  the  tibia,  so  that  the  original  tough  sole  of  the  foot  still 
forms  the  lower  end  or  face  of  the  stump  (in  Syme's  and  the  original 


A  TEXTBOOK  OF  SURGERY 


Pirogofl  amputations  the  skin  forming  the  face  of  the  stump  is  that  of  the 
back  of  the  heel,  which  is  not  good  for  withstanding  pressure,  as  the  trouble 
caused  by  new  shoes  often  bears  witness).  The  OS  caleis  is  fixed  to  the 
lower  end  of  the  tibia  with  suture  or  a  temporary  steel  peg,  which  is  removed 
in  three  weeks. 

(3)  The  Subastragaloid  Amputation  (by  external  racket  incision).  The 
handle  of  the  racket  stalls  at  the  back  of  the  os  caleis  and  is  carried  forward 
horizontally  one  inch  below  the  external  malleolus  till  it  reaches  the  base 
ol  the  fifth  metatarsal,  when  it  is  swept  as  a  circular  incision  over  the  dorsum 
and  round  the  sole  to  complete  the  loop  of  the  racket.  The  incision  is 
down  to  the  bone  and  the  tissues  are  raised  in  the  dorsal  part  of  the  incision 
till  the  astragalo-scaphoid  joint  is  reached  and  opened.  The  astragal o- 
calcaneal  joint  is  opened  from  the  outer  side  and,  gradually  twisting  the 


Fig.  222.     Line  of  skin  incision  for  amputation  of  the  foot  below  the  astragalus 

(subastragaloid  amputation). 


foot  into  a  more  complete  varus  position,  separation  of  the  os  caleis  from 
the  astragalus  effected,  and,  maintaining  this  torsion  still  further,  the  tissues 
of  the  sole  are  cleared  from  the  inner  and  lower  and,  finally,  the  outer  surface 
of  the  os  caleis,  when  the  foot  will  be  removed. 

The  resulting  stump  is  wide  and  elastic  and  faced  by  the  tough  integu- 
ments of  the  heel,  but  more  tissue  is  needed  than  in  the  previously  described 
operations.  As,  however,  the  os  caleis  is  removed,  the  operation  may  be 
feasible  where  some  disease  of  this  bone  is  present.  The  modified  Pirogofl 
gives  the  best  stump  of  all,  but  can  only  be  done  where  the  os  caleis  is  free 
fi  on i  disease,  as  in  accident  cases.  The  stump  of  a  Syme's  amputation  is 
good,  though  inferior  to  the  others  ;  however,  it  is  possible  to  perform 
this  amputation  where  disease  has  spread  too  high  in  the  bones  or  integu- 
ments  to  permit  of  the  others  being  used. 


AFFECTIONS  OF  THE  FOOT  537 

AFFECTIONS  OF  THE  FOOT 

Congenital  defects  are  considered  under  Deformities. 

Of  acute  infections  the  most  important  are  osteomyelitis,  gonorrhoeal 
infection  of  the  tarsal  joints,  and  gout. 

(a)  Acute  Infective  Osteomyelitis.  This  most  commonly  starts  in 
the  os  calcis  under  the  epiphyseal  cartilage  at  the  posterior  end,  and  presents 
the  usual  signs — pain,  swelling,  tenderness,  and  sub-periosteal  abscess,  with 
severe  constitutional  disturbance. 

More  rarely  the  infection  commences  in  the  astragalus,  the  signs  being 
then  those  of  acute  infection  of  the  ankle-joint.  The  other  tarsal  bones 
are  seldom  affected  in  this  way. 

Treatment.  Free  incision  and  drainage.  In  severe  cases  the  os  calcis 
may  be  removed  subperiosteally  by  an  external  incision  along  its  length. 
The  astragalus,  if  involved,  will  most  likely  need  removal  either  by  an 
anterior  incision  displacing  the  extensor  tendons  or,  better,  by  the  external 
route  of  Kocher  for  excision  of  the  ankle.  Where  suppuration  persists  in 
spite  of  free  drainage  and  excision,  Syme's  amputation,  or  the  complete 
tarsectomy  of  Mickulicz  will  be  indicated. 

(6)  Gonorrhceal  Infection  of  the  Tarsus.  This  is  found  as  a  tender 
swelling  over  the  dorsum  of  the  foot,  painful  enough  to  prevent  walking, 
with  slight  redness  of  the  skin.  The  condition  resembles  tuberculosis  of 
these  joints,  but  the  more  rapid  onset,  the  age  (young  adult  life),  and  the 
coincident  urethritis  or  vaginitis  will  help  to  avoid  error.  The  freedom  of 
the  ankle-joint  from  swelling  or  limitation  of  movement  will  exclude  affec- 
tion of  this  joint.  The  arch  of  the  foot  often  gives  way  (gonorrhceal  flat- 
foot).     Gout  only  needs  mention  to  exclude  errors  in  diagnosis. 

Treatment.  Rest  in  a  plaster-case  and  administration  of  vaccines, 
while  the  original  focus  is  carefully  treated. 

(c)  Tuberculosis  of  the  Bones  of  the  Foot.  Infection  of  the  astra- 
galus resulting  in  tuberculous  ankle  has  already  been  mentioned.  The 
os  calcis  may  be  affected  alone,  causing  pain  and  limping,  with  a  swelling 
over  the  outer  side  of  the  bone  and  formation  of  abscess  and  sinuses.  Radio- 
graphs will  show  rarefaction  of  bone  in  early  cases. 

Treatment.  Confinement  in  a  plaster-case  with  the  foot  off  the  ground, 
curetting  sinuses,  excising  the  bone  in  advanced  cases,  or,  failing  this, 
osteoplastic  resection  or  Syme's  amputation. 

Tuberculosis  of  the  other  tarsal  bones  is  likely  to  be  widespread  owing 
to  the  large  synovial  sheath  which  puts  the  scaphoid,  cuneiforms,  cuboid, 
and  bases  of  the  three  middle  metatarsals  in  connexion.  Starting  in  one 
of  these  bones,  the  central  part  of  the  foot  is  soon  involved  with  painful, 
tender  swelling  and  formation  of  cold  abscesses  and  sinuses.  The  patient's 
age  (usually  childhood),  the  slower  progress,  and  the  absence  of  gonorrhoea 
distinguish  from  that  infection. 

Treatment.  This  is,  as  usual,  by  rest  in  plaster  with  the  foot  of!  the 
ground ;    in  severe  cases  curetting  sinuses,  bismuth  paste,  removing  the 


A  TEXTBOOK  OF  SURGERY 

bones  by  lateral  incisions;  eventually  amputation  may  be  needed  in 
inveterate  cases.  The  site  of  this  depending  on  the  involvement  of  bones 
and  tissues,  as  there  is  some  chance  of  the  os  calcis  escaping,  a  Pirogofi 
or  a  subastragaloid  amputation  maybe  possible.  In  middle-aged  persons 
with  sinuses  amputation  is  advisable. 

((/)  Tuberculosis  of  the  metatarsal  bones  is  common,  in  the  digits  rare, 
and  resembles  similar  conditions  in  the  hand  in  pathology,  diagnosis,  and 
treatment. 

{e)  Tuberculous  bursitis,  especially  of  the  extensor  sheaths,  is  not 
uncommon. 

(/)  Neuropathic  manifestations  are  chiefly  confined  to  the  occurrence  of 
perforati)ig  ulcers  arising  under  the  heads  of  the  metatarsals  from  ulceration  . 
of  corns  in  the  partially  devitalised  tissues.     The  result  of  this  slow  destruc- 
tion is  that  a  sinus  forms,  leading  down  to  the  bone,  which  becomes  carious. 

Treatment.  Keeping  the  patient  off  the  feet  for  some  months,  with 
careful  antiseptic  dressing,  and  paring  away  all  hard  epidermis,  will  usually 
cure,  but  where  the  condition  spreads  in  the  bones  it  will  be  necessary  to 
excise  the  metatarsal. 

(</)  Tumours.  All  manner  of  tumours  of  connective-tissue  formation 
are  found  in  this  region,  but  none  are  especially  noteworthy  except  subungual 
exostosis  and  melanotic  sarcomas. 

Subungual  Exostosis.  This  is  found  under  the  nail  of  the  great  toe 
as  a  bony  outgrowth  which  pushes  the  nail  upwrards,  causing  pain  by  its 
pressure  and  distinguished  from  inflammatory  swellings  by  its  hardness  and 
absence  of  a  vascularity  (Fig.  159,  p.  380). 

Treatment.  The  nail  should  be  removed  and  the  exostosis  cut  away 
with  a  chisel  till  level  with  the  bone. 

Melanotic  sarcomas  are  similar  in  pathology  and  treatment  to  those  of 
the  finger-pulp. 

Deformities  of  the  Foot  :  Club-foot,  Talipes.  A  great  variety  of 
conditions  both  of  congenital  and  acquired  origin  are  grouped  under  this 
heading.  In  these  conditions  there  is  a  deviation  of  the  foot  at  the  ankle  or 
mid-tarsal  joints  or  both,  the  direction  varying  in  different  types.  The 
deformities  are  often  described  as  talipes  with  a  qualifying  adjective 
describing  the  type  present.  The  movements  of  flexion  and  extension  at 
the  ankle-joint,  inversion  and  eversion  at  the  talo-calcaneal  and  mid-tarsal 
joints,  alteration  of  the  arch  at  the  tarso-metatarsal  joints,  are  involved  in 
these  deformities,  and  the  positions  assumed  are  for  convenience  named  as 
follows  : 

(1)  Plantar  flexion  at  the  ankle  (sometimes  called  extension),  or  tip- 
toe position  of  the  foot,  is  known  as  the  equinus  position,  and  deformity  of 
this  sort  as  talipes  iquinus. 

(2)  Dorsinexion  at  the  ankle  (sometimes  called  extension,  since  caused 
by  the  extensor  group  of  muscles)  associated  with  protrusion  of  the  heel 
downwards  is  the  calcaneal  position,  and  deformity  of  this  sort  is  talipes 
calcaneus. 


CONGENITAL  CLUB-FOOT  539 

(4)  Inversion  of  the  foot  is  called  talipes  varus. 

(5)  E version  is  called  talipes  valgus. 

When  the  arch  is  exaggerated  it  is  known  as  pes  cavus,  hollow  or 
claw-foot ;  when  diminished,  as  pes  planus,  flat-  or  splay-foot.  These 
positions  may  be  combined  and  certain  combinations  are  usual.  Thus 
equino-varus  and  calcaneo-valgus  are  common  types  of  congenital  deformity, 
and  pes  cavus  is  a  frequent  accompaniment  of  most  types,  congenital  or 
acquired. 

Causes  of  Club-foot.    These  may  be  congenital  or  acquired. 

The  cause  of  congenital  talipes  is  probably  in  most  instances  over- 
pressure and  moulding  in  utero  from  deficient  liquor  arrmii  at  some  period 
of  development,  perhaps  quite  early.  The  position  of  the  feet  in  the  normal 
infant  render  this  hypothesis  likely,  since  the  feet  at  birth  are  habitually 
folded  in  a  varus  position  and  have  a  tendency  in  this  direction  for  several 
months  after,  being  normally  corrected  by  kicking  and  rubbing  the  inner 
sides  of  the  limbs  together  in  the  natural  movements  of  the  infant.  If 
this  position  were  exaggerated  there  would  be  definite  talipes  equino- 
varus.  Should  one  of  the  feet  become  displaced  in  utero  it  may  assume  the 
calcaneus  position  and  the  moulding  of  the  overtight  uterus  maintains  the 
position,  so  that  in  some  cases  one  finds  varus  on  one  side,  calcaneus  on 
the  other,  nicely  fitting  together  as  if  moulded  in  this  position.  Other 
congenital  causes  are  paralyses  ;  thus  talipes  is  commonly  associated  with 
spina?  bifida  where  the  cord  or  nerves  are  involved.  Acquired  causes  are 
many,  but  the  most  important  by  far  are  infantile  paralysis  and  static 
deformities,  causing  flat-foot  and  decubitus  equinus  from  prolonged  rest 
without  support  for  the  foot,  whether  in  bed  or  in  splints.  Spastic  paralysis 
of  upper-segment  origin  accounts  for  a  fair  proportion  of  cases  ;  paralyses  of 
nerves,  inflammation  of  joints,  injuries,  compensatory  deformity  (as  the 
pointed  toes  with  shortening  of  the  leg  from  hip-disease),  and  neuromimesis 
also  provide  examples. 

(a)  Congenital  Club-foot.  There  are  two  main  varieties.  The  more 
common  is  equino-varus,  the  foot  being  strongly  inverted  so  that  at  first 
sight  the  condition 'might  be  regarded  as  pure  varus,  but  on  closer  inspection 
the  heel  will  be  found  drawn  up  and  the  name  equino varus  is  fully  justified. 
Pure  varus  and  pure  equinus  of  congenital  origin  are  very  rare.  The  second 
group  contains  cases  where  the  heel  is  down  and  the  toes  dorsiflexed,  and 
usually  with  some  eversion,  i.e.  the  condition  is  calcaneo-valgus. 

(1)  Congenital  Talipes  Equino-varus.  Anatomy.  The  deformity  is 
at  the  mid-tarsal  and  ankle-joints,  the  foot  being  inverted  and  bent 
laterally  on  itself  in  a  sickle  shape,  concavity  inwards,  owing  to  the  posterior 
part  being  drawn  up  by  the  tendo  Achillis  and  the  anterior  by  the  anterior 
tibial  muscles.  In  other  words,  the  equinus  affects  the  posterior  part  of 
the  foot  rather  than  the  anterior.  There  is  a  sliding  inwards  of  the 
scaphoid  and  cuboid  on  the  astragalus  and  os  calcis  ;  the  neck  of  the 
astragalus  is  twisted  inwards.  These  changes  are  more  marked  as  the 
patient  grows   older,  and   especially  when   the   foot   has   been   used   for 


540  A  TEXTBOOK  OF  SURGERY 

walking  :  in  severe  deformity  the  tubercle  of  the  scaphoid  may  touch  the 
interna]  malleolus. 

Tendons  and  Ligaments.  The  tendb  Achillis  and  tibialis  portions  are 
shortened  ;  the  tendons  on  the  dorsum  are  short  and  displaced  inwards. 
The  dorsal  ligaments  are  lengthened,  while  the  lower  ligaments — especially 
the  calcaneo-scaphoid,  plantar  ligaments,  plantar  fascia,  and  the  short 
muscles  of  the  sole — are  shortened. 

The  skin  shows  a  well-marked,  transverse  crease  below  the  internal 
malleolus  marking  the  increase  in  the  arch  :  later,  when  the  patient  walks. 
there  is  also  a  longitudinal  crease  along  the  sole  of  the  foot,  which  is  crumpled 
laterally  from  the  pressure  on  its  outer  side  in  walking.  When  the  child 
has  walked  for  some  time  the  deformity  becomes  more  pronounced,  the  foot 


Fig.  223.     Congenital  talipes  equino-varus  in  an  infant  of  3  months ;    the 
inversion  or  varus  part  of  the  deformity  is  most  marked. 

rotating  further  over  so  that,  whereas  at  first  the  outer  side  is  on  the  ground, 
in  time  the  dorsum  takes  the  body-weight.  The  head  of  the  astragalus 
becomes  more  prominent  on  the  dorsum  and  adventitious  bursas  result  from 
the  pressure  of  walking  on  the  dorsum.  The  skin  on  the  dorsum  is  thickened, 
while  on  the  heel  it  remains  fine  and  delicate.  The  creases  in  the  sole 
become  more  marked,  the  joints  undergo  degenerative  changes,  and  the 
muscles  atrophy.  The  gait  is  awkward,  the  inversion  of  the  feet  causing 
these  to  knock  together  in  walking  unless  one  be  carried  over  the  other 
with  an  action  resembling  a  bicyclist ;  nevertheless  some  patients  with 
this  deformity  can  walk  a  long  distance  when  grown  up. 

Treatment.  The  deformity  which  has  taken  months  to  occur  inutero 
will  take  as  many  years  after  birth  to  cure  completely.  Rapid  cure  is  not 
possible  (this  does  not  imply  that  correction  cannot  be  done  quickly),  but 
with  patient  overlooking,  if  parents  will  only  take  the  trouble  to  attend 
for  advice,  perfect  cure  may  be  obtained.  These  cases  need  to  be  under 
observation  for  at  least  five  years.     Until  the  child  is  ready  to  walk  the 


CONGENITAL  TALIPES  EQUINO- VARUS 


541 


treatment  can  be  mild,  but  the  critical  point  is  the  commencement  of  walking. 
The  child  must  be  able  to  place  the  foot  with  the  sole  flat  on  the  ground 
when  it  is  time  to  walk,  and  if  kept  walking  with  corrected  foot  for  about 
five  years  there  will  be  no  tendency  to  relapse  as  the  foot  will  have  acquired 
the  correct  shape.  Treatment  should  commence  at  birth,  the  foot  being 
massaged  and  manipulated  thrice  daily,  twisting  it  into  the  opposite  direc- 
tion from  the  deformity,  i.e.  attempting  to  place  it  in  a  position  of  calcaneo- 
valgus  :  the  manipulation  should  not  be  painful.  The  curvature  of  the 
foot  can  be  in  part  corrected  by  applying  a  straight  internal  splint  between 
the  manipulations.  In  this  way  the  milder  cases  will  be  able  to  place  the 
foot  flat  on  the  ground  by  the  end  of  the  year.     In  the  more  rebellious  cases 


Fig.  223a.     The  same  feet  seen  from  behind.     Note  in  addition  to  the  varus 

deformity  the  heels  are  drawn  up  (equinus)  and  on  the  left  side  the  transverse  crease 

in  the  sole  is  well  marked. 


the  same  measure  will  suffice  at  first,  severe  measures  being  of  little  advan- 
tage in  the  first  few  months,  but  when  the  time  for  walking  is  getting  near 
and  the  position  is  not  improving  sufficiently,  i.e.  about  the  end  of  the  first 
year,  the  foot  should  be  forcibly  corrected  ;  this  is  best  done  by  a  preliminary 
division  of  the  plantar  fascia  and  tibialis  anticus  and  posticus  tendons, 
followed  in  ten  days  by  wrenching  the  foot  into  a  position  of  valgus,  after 
which  the  tendo  Achillis  is  divided  and  the  foot  placed  in  plaster  in  the 
calcaneo- valgus  position  for  a  month.  The  wrenching  may  need  repetition 
two  or  three  times  before  the  over-correction  is  satisfactory.  Whether  the 
correction  is  by  simple  manipulation  or  wrenching,  as  soon  as  the  foot  can 
be  over-corrected  it  should  be  placed  in  an  L-shaped  tin  splint  (night-shoe) 
when  not  being  massaged,  and  as  soon  as  the  child  begins  to  get  on  the 
feet  a  walking  instrument  must  be  provided  consisting  of  irons  to  the  knee, 


A  TEXTBOOK  OF  SURGERY 

a  toe-raising  spring,  and  varus  T-strap.  The  child  wears  the  walking 
instrument  by  day,  the  tin-splint  by  night,  the  movements  of  correction 
being  made  as  before.  Inversion  of  the  foot  can  be  obviated  by  an  artificial 
sartoriua  or  rubber  strap  attached  to  a  pelvic  band  above  and  to  the  leg- 
iron  below,  encircling  the  limb  twice  in  a  direction  such  that  its  traction 
produces  eversion  of  the  foot.  This  plan  will  be  enough  for  cases  met  at 
1  tilth  or  up  to  two  or  three  years,  after  which  more  severe  measures  are 
needed.  The  most  satisfactory  is  the  modified  Phelps's  operation  (Open- 
si  ! aw).  This  consists  in  raising  a  triangular  skin-flap  from  the  sole,  the 
apex  being  at  the  tubercle  of  the  scaphoid.  After  raising  this  flap  the 
structures  of  the  inner  half  of  the  sole  are  divided  to  the  bone,  including  the 
short  muscles  of  the  great  toe,  the  plantar  fascia,  internal  plantar  artery 
and  nerve,  and  part  of  the  long  plantar  ligament,  as  well  as  the  tendons  of 
the  tibialis  anticus  and  posticus.  The  flap  is  then  replaced,  the  V  becoming 
a  Y.  In  this  way  the  transverse  curve  of  the  foot  is  corrected,  the  shortened 
inner  border  being  elongated.  Tenotomies  and  wrenching  follow  this 
operation  and  continued  use  of  walking  instrument  and  night-shoe.  This 
treatment  should  suffice  up  to  about  eight  years,  after  which  neglected  and 
bad  cases  can  hardly  be  sufficiently  corrected  without  operation  on  the 
bones.     Two  plans  for  removing  bone  are  in  vogue  : 

(1)  Cuneiform  tarsectomy,  by  turning  a  flap  from  the  outer  side,  dis- 
placing the  dorsal  tendons,  and  removing  a  wedge  of  bone  with  the  base 
outwards,  consisting  of  the  anterior  part  of  the  os  calcis,  the  head  of  the 
astragalus,  and  the  cuboid. 

(2)  Removal  of  the  astragalus,  which  can  be  done  piecemeal  through 
an  anterior  incision,  pushing  the  tendons  to  one  side.  The  latter  is  the 
less  damaging  operation. 

After  these  operations  after-treatment  must  be  even  more  prolonged  than 
when  the  case  was  caught  early,  since  complete  cure  cannot  be  possible, 
and  as  long  as  this  has  not  been  achieved  there  is  always  a  tendency  to 
relapse.  Where  inversion  of  the  foot  persists  osteotomy  of  the  lower  end 
of  the  femur  will  correct  it.  To  sum  up,  whatever  operative  steps  are  taken, 
the  deformity  should  be  over-corrected  and,  later,  attempts  should  be  made 
to  obtain  full  movement  in  all  directions.  It  is  not  difficult  to  obtain 
correction,  but  the  foot  must  be  made  to  function  for  a  number  of  years  in 
the  corrected  position  before  the  case  can  be  regarded  as  cured.  Perfect 
results  will  only  be  obtained  in  the  cases  where  tenotomy  and  wrenching, 
or  at  most  Phelps's  operation,  suffice  to  correct  the  deformity ;  for  which 
reason  treatment  should  be  commenced  at  the  earliest  moment  and  kept  up 
assiduously  for  several  years. 

(2)  Congenital  Talipes  Calcaneus.  There  is  often  a  considerable  element 
of  valgus  in  these  deformities.  The  heel  projects  downwards,  the  toes  are 
dorsiflexed,  the  anterior  tibial  tendons  taut,  and  eversion  common.  The 
position  distinguishes  it  from  the  paralytic  variety,  in  which  the  toes  are 
dropped  as  well  as  the  heel,  producing  the  condition  of  pes  cavus.  The 
condition  is  less  common  than  equino-varus  and  usually  of  slighter  degree. 


PARALYTIC  TALIPES  543 

Treatment.  Constant  manipulation  from  birth,  attempting  to  convert 
the  deformity  into  one  of  equino-varus,  and  an  anterior  splint  to  depress  the 
toes  will  help  ;  this  may  be  made  of  malleable  iron  and  straightened  out 
as  the  deformity  diminishes.  If  much  deformity  persists  when  walking 
commences  tenotomy  of  the  anterior  tibial  tendons  may  be  performed, 
or  this  combined  with  wrenching,  but  these  measures  will  seldom  be  needed 
as  the  tendency  is  to  recovery.  Shortening  of  the  tendo  Achillis  might  be 
needed  in  rebellious  cases. 

(6)  Paralytic  Club-foot.  These  affections  are  commonly  due  to 
infantile  paralysis,  less  often  to  nerve-lesions  ;  in  either  case  the  paralysis 
is  flaccid.  Less  common  are  the  spastic  paralyses  from  upper-segment 
lesions,  and  amongst  the  group  of  flaccid  paralysis  are  conveniently  placed 
the  forms  due  to  decubitus  and  neuritis,  generally  alcoholic  in  origin. 

(1)  Talipes  Equinus.  This  is  usually  due  to  paralysis  of  the  anterior 
tibial  muscles  in  infantile  paralysis  or  neuritis  and  injury  of  the  anterior 
tibial  nerves.  In  either  case  the  deformity  arises  from  want  of  care  to  see 
that  the  foot  is  kept  at  right  angle  with  the  leg  in  such  cases  and  thus  allowing 
the  paralysed  muscles  to  become  overstretched,  while  the  antagonistic 
tendo  Achillis  takes  in  slack  and  becomes  contracted.  Similar  conditions 
are  found  in  patients  confined  to  bed,  from  pressure  of  the  clothes  producing 
overstretching  of  these  muscles. 

The  position  of  equinus,  compensating  shortening  of  the  leg  in  tuber- 
culous hip-disease,  is  an  allied  condition. 

The  degree  of  deformity  varies  considerably. 

(a)  The  slighter  cases  admit  of  dorsiflexion  at  a  right  angle,  being  then 
checked  by  the  tense  tendo  Achillis  (right-angled  equinus)  ;  this  has  the 
effect  of  shortening  the  stride  and  causing  the  patient  to  limp. 

(6)  In  more  severe  degrees  the  heel  cannot  be  placed  on  the  ground,  while 
corns  appear  under  the  metatarsal  heads  and  the  arch  of  the  foot  is  excessive 
(pes  cavus). 

(c)  In  still  more  severe  degrees  the  dorsum  of  the  foot  may  face  the 
ground.  In  spastic  equinus,  the  position  differs  in  that  the  os  calcis  is 
more  raised  by  the  tendo  Achillis  than  in  the  paralytic  and  decubitus  varieties, 
in  which  a  good  deal  of  the  deformity  is  simply  dropping  of  the  front  of  the 
foot. 

Treatment.     Where  secondary  to  a  short  limb  no  treatment  is  needed. 

The  paralytic  cases  should  be  prevented  by  not  allowing  the  foot  to 
drop  in  cases  of  poliomyelitis,  nerve  injury,  or  where  patient  is  confined 
long  to  bed.  Pressure  of  the  bedclothes  is  taken  off  the  toes  with  a  cradle 
and  the  feet  kept  up  to  a  right  angle  by  propping  with  warm  bottles  or, 
if  the  condition  is  likely  to  be  protracted,  by  the  use  of  the  L-shaped  .tin 
shoe. 

Where  the  condition  is  actually  present  some  idea  of  the  prognosis  can 
be  obtained  by  plantar-flexing  the  foot  as  much  as  possible  and  seeing  if 
any  power  of  dorsiflexion  remains  :  if  there  is  such  power  recovery  should 
be  fair,  but  otherwise  there  is  little  likelihood  of  recovery  short  of  tendon- 


544  A  TEXTBOOK  OF  SURGERY 

graft  ing  or  nerve-splicing,  which  should  be  considered  where  there  is  complete 

paralysis  oi  the  extensors.  When  there  is  some  prospect  of  recovery  the 
tendo  Achillis  should  be  divided  subcutaneously  and  a  walking  instrument 
with  toe-raising  spring  worn  by  day  and  a  tin  shoe  at  night  for  at  least  a 
year,  while  the  affected  muscles  should  be  well  massaged.  Where  no 
recovery  of  muscles  is  possible  the  position  should  be  corrected  by  tenotomy 
as  before,  with  perhaps  removal  of  the  astragalus  (in  neglected  cases), 
followed  by  the  use  of  walking  instrument  and  possibly  tendon-grafting. 
The  plantar  fascia  should  be  divided  where  there  is  much  pes  cavus.  If 
the  ankle  be  in  a  flail  condition  from  paralysis  of  the  anterior  and  calf 
muscles  as  well,  an  arthrodesis  of  the  ankle  and  mid-tarsal  (astragalo- 
scaphoid)  joints  should  be  done  and  a  wide  piece  of  skin  removed  from  the 
dorsum  of  the  joint.  Transverse  suturing  of  the  gap  thus  made  will  prevent 
recurrence  of  equinus  (Jones). 

In  spastic  cases  the  tendo  Achillis  must  be  lengthened  by  the  Z  method, 
tenotomy  being  insufficient.  The  propriety  of  dividing  posterior  nerve-roots 
to  diminish  the  spasm  will  have  to  be  considered.  In  any  case  the  out- 
look is  much  less  good  than  in  the  paralytic  cases. 

(2)  Paralytic  Eqyino-varus.  This  usually  results  from  infantile  paralysis, 
injuries  to  the  external  popliteal  nerve,  and  in  the  peroneal  form  of  muscular 
dystrophy  ;   it  is  rare  in  spastic  paralysis. 

The  condition  is  like  equinus,  but  in  addition  the  sole  is  turned  inwards 
from  palsy  of  the  peronei. 

Treatment  is  on  the  same  lines  as  for  equinus  :  tenotomy  of  the  tendo 
Achillis,  followed  by  use  of  a  walking  instrument  which  has  in  addition 
a  varus  T-strap,  and  where  the  paralysis  is  permanent,  tendon-grafting, 
such  as  part  of  the  tibialis  anticus  or  of  the  tendo  Achillis,  into  the  peronei 
may  be  done. 

(3)  Paralytic  valgus  is  uncommon  and  treated  on  similar  lines. 

(4)  Paralytic  Talipes  Calcaneus.  This  usually  results  from  infantile 
paralysis  affecting  the  calf  muscles  and  rendering  slack  the  tendo 
Achillis. 

The  appearance  is  different  from  the  congenital  form,  since,  though  the 
heel  drops,  the  anterior  part  of  the  foot  is  not  dorsiflexed,  consequently 
there  is  always  considerable  pes  cavus  combined  with  this  deformity.  The 
os  calcis  is  loose  and  wobbles  in  walking ;  the  weight  is  taken  on  the  back 
of  the  heel,  which  is  thrust  forward,  making  the  deformity  worse.  The 
short  muscles  of  the  foot  and  plantar  fascia  shorten  and  the  cavus  position 
becomes  fixed. 

Treatment.  This  has  not  been  satisfactory.  Whitman,  however,  claims 
good  results  by  making  an  external  incision  from  the  back  of  the  external 
malleolus  round  the  tip  of  this  to  the  inner  side  of  the  dorsum  of  the  foot. 
The  astragalus  is  removed,  the  foot  dislocated  back  on  the  tibia,  and  the 
peronei  grafted  into  the  os  calcis — at  the  same  time  performing  arthrodesis 
of  the  os  calcis  and  cuboid  with  the  lower  end  of  the  tibia  :  a  light  brace  is 
worn  for  a  year  to  maintain  extension  of  the  foot. 


PES  CAVUS 


545 


The  pes  cavus  may  be  corrected  by  division  of  plantar  fascia  and  short 
muscles  of  the  foot. 

(5)  Pes  Cavus  ;  Hollow  or  Claw-foot ;  Pes  Excavatus.  The  term  pes 
arcuatus  is  also  applied  by  some  authors  to  this  condition,  while  others 
reserve  it  for  cases  of  hollow  foot  where  the  arch  is  increased  but  the  heel 
and  toe  are  in  the  same  plane  and  movements  normal  (this  "  high  instep  " 
is  simply  an  exaggeration  of 
the  normal  arch  and  found  in 
quite  athletic  persons),  while 
pes  plantaris  is  reserved  for 
those  cases  where  the  ball  of 
the  toe  is  below  the  heel  and 
dorsiflexion  limited.  The  cause 
seems  to  be  slight  degrees  of 
infantile  paralysis,  either  of 
anterior  tibial  or  calf  muscles 
or  both,  resulting  in  dropping 
of  both  toes  and  heel  and 
secondary  shortening  of  the 
plantar  fascia  and  short  muscles 
of  the  foot.  The  condition 
(when  marked)  is  obvious  ;  the 
highly  arched  foot  not  touch- 
ing the  ground  on  either  side, 
the  hyperextension  of  the  first 
joint  of  the  toes  and  flexion  of 
the  distal  joints,  the  contracted 
plantar  fascia  and  corns  under 
the  heads  of  the  metatarsals 
are  distinctive. 

Treatment.  Where  the  un- 
derlying condition  is  equinus 
or  calcaneus  these  should  be 
treated. 

Where  the  condition  is 
chiefly  one  of  cavus,  if  slight 

and  only  some  right-angled  equinus  is  present  the  tendo  Achillis  should  be 
divided  and  prevented  from  recontracting  by  use  of  the  toe-raising  spring 
or  removing  the  heel  of  the  boot  and  placing  a  bar  across  the  sole  at  the 
ball  of  the  foot,  so  that  the  patient  must  walk  on  the  heel  (Jones).  Where 
the  condition  is  worse  the  plantar  fascia  and  extensors  of  the  toes  require 
division  and  the  foot  should  be  wrenched  into  shape.  Jones  advocates  ki 
addition  transplanting  the  extensor  hallucis  into  the  head  of  the  first  meta- 
tarsal. In  more  advanced  cases  with  rigidity  and  severe  equinus  the 
astragalus  should  be  removed  and  the  heads  of  the  metatarsal  bones  excised, 
possibly  with  the  toes  as  well,  and  the  extensor  tendons  being  sutured  to 
i  35 


Fig.  224.      Paralytic    talipes   calcaneus   and    pes 

cavus.     Note  the  wasted  calf  and  dropping  of  the 

heel  on  the  affected  side. 


546  A  TEXTBOOK  OF  SURGERY 

the  ends  of  the  metatarsal  bones.     Walking  apparatus  to  maintain  dorsi- 
flexion  will  be  needed  in  all  cases. 

(c)  Traumatic  Club-foot.  Eqnino-varus  arising  fxom  injury  to  the 
lower  epiphysis  of  the  tibia  has  been  mentioned  in  injuries  of  this  part. 
Flat-loot  following  on  injuries  is  discussed  under  Flat-foot. 

(d)  Static  Deformities.  Flat-  or  splay-foot,  or,  as  it  is  sometimes 
called,  acquired  talipes  valgus  and  pes  planus,  is  the  chief  deformity  of 
this  nature,  though  hallux  valgus,  metatarsalgia,  described  later,  are  also 
of  static  origin. 

In  this  affection  the  foot  is  everted  and  there  is  some  dropping  of  its 
arch  the  former  condition  being  ••  valgus,"  the  latter  "planus."  This  is 
the  commonest  deformity  of  the  feet  and  nearly  always  acquired,  though 
congenital  cases  are  sometimes  met  with  associated  with  calcaneus,  more 
rarely  with  equinus. 

Causes.  The  usual  cause  of  the  feet  giving  way  is  from  over-increase  in 
weight  compared  with  the  strength  of  the  feet,  and  hence  it  is  so  common 
in  adolescents  who  are  rapidly  growing,  often  ill-nourished,  and  have  to 
maintain  the  erect  position  for  many  hours  at  a  stretch,  and  is  thus  akin  to 
the  deformities  of  knock-knee  and  scoliosis.  Flat-foot  is  not  uncommon  in 
small  children,  due  to  the  flabbiness  caused  by  rickets,  which  not  only 
renders  bones  soft  but  impairs  muscular  tone.  Injuries  (Pott's  fracture, 
fracture  of  the  os  calcis),  infections  (gonorrhoea),  rheumatoid  and  neuro- 
pathic changes  in  the  tarsal  joints,  account  for  some  cases. 

(1)  Flat-foot  of  Children  and  Adolescents.  The  main  factors  in  the 
production  of  this  deformity  are  weakness  of  the  muscles  and  ligaments, 
which  support  the  arch  and  preserve  the  normal  position  of  the  foot,  as 
compared  with  the  increasing  weight  of  the  patient  ;  long  periods  of  standing 
still  ;  not  least,  the  faulty  position  often  assumed,  i.e.  standing  with  the 
feet  everted.  This  faulty  position  is,  unfortunately,  taught  by  drill- 
sergeants  and  other  instructors  of  youth.  Standing  with  the  heels 
together  and  the  toes  at  an  angle  of  forty-five  degrees  is  a  relic  of  the  flint- 
lock days,  when  to  concentrate  musket-fire  soldiers  were  massed  close 
together  and  it  was  obvious  that  by  turning  the  toes  out  the  rear  rank 
could  be  got  closer  to  the  front  rank  and  more  men  placed  on  any  given 
space  of  ground,  and  thus  the  military  tactics  of  bygone  ages  have  their 
effect  on  the  feet  of  modern  youth.  Other  factors  are  enfeebling  disease, 
anaemia,  &c. 

The  primary  defect  is  a  deviation  of  the  foot  outward,  which  is  a  position 
of  weakness  (Whitman).  In  many  cases  the  arch  is  good  at  first  but  the 
foot  painful,  splayed  out,  and  the  gait  poor  and  shambling.  Later  there  is 
sinking  of  the  arch  from  weakness  of  the  tibialis  posticus,  stretching  of  the 
long  plantar  and  calcaneo-scaphoid  ligaments.  When  the  deformity  is 
well  ma  iked  the  foot  is  canoe-shaped,  i.e.  bulges  on  the  inner  side  instead 
ing  concave.  The  heel  appears  short,  the  head  of  the  astragalus  is  sunk 
between  the  scaphoid  and  os  calcis,  the  tubercle  of  the  scaphoid  is  directed 
downward,  and  there  is  outward  displacement  of  the  foot  at  the  mid-tarsal 


FLAT-FOOT 


547 


joint  often  associated  with  hallux  valgus  and  occasionally  with  spasm  of 
the  peronei. 

Signs.  The  patient  may  complain  of  pain  in  the  feet,  increased  on 
standing — the  pain  being  felt  under  the  instep,  on  the  dorsum  of  the  foot, 
in  the  heel,  and  up  the  front  of  the  leg.  This  applies  to  adolescents  ;  children 
are  usually  brought  because  the  gait  is  bad.  On  examination  the  arch  may 
be  dropped  with  the  inward  bulging  already  described,  but  often  there  is 
little  wrong  with  the  arch  and  it  is  the  gait  with  eversion  of  the  foot  which 
is  characteristic.  A  low  arch  does  not  mean  necessarily  flat-foot,  and  is 
often  present  with  great  activity  and  athletic  power.  It  is  important  not 
to  miss  early  cases,  which  best  react  to  treatment ;  hence,  if  the  feet  are 
everted  and  the  pain  described  is  present  and  the  feet  tire  easily  the  con- 


FiG.  225.     Foot-prints.     A,  Normal.     B,  Moderate  flat-foot.     C,  Severe  flat-foot. 


dition  must  be  treated  as  flat-foot.  In  more  severe  cases  the  arch  is  flattened, 
but  may  be  restored  by  standing  on  tiptoe  or  by  manipulation.  In  still  more 
advanced  cases  there  is  no  improvement  on  assuming  the  tip-toe  position 
and  the  impress  of  the  foot  (made  by  damping  it  and  standing  on  a  sheet 
of  paper,  outlining  the  part  made  damp  by  the  foot)  is  markedly  flattened, 
little  of  the  hollowing  of  the  instep  remaining  (Fig.  225).  The  muscles  are 
flabby,  the  joints  stiff,  the  gait  loses  its  spring  and  is  clumsy  and  shuffling. 

Treatment.  Much  trouble  would  be  saved  if  the  right  and  natural 
manner  of  standing  and  walking  were  taught  in  early  youth  instead  of  the 
erroneous  styles  of  drill-  and  dancing  masters.  The  normal  position  for 
standing  is  with  the  feet  a  few  inches  apart  and  pointing  straightforwards, 
not  at  all  everted.  In  walking  the  toes  should  be  pointed  straight  forward 
and  the  feet  placed  alternately  almost  completely  in  front  of  each  other 
and  not  to  the  side.  Further,  the  boots  should  be  straight  along  their 
inner  side  and  not  curved  out,  as  usually  done  (to  make  the  toes  pointed), 
which  causes  hallux  valgus,  a  common  antecedent   to  flat-foot.     When 


t>  A  TEXTBOOK  OF  SURGERY 

flat-foot  is  actually  present  the  sole  and  heel  should  be  thickened  a  quarter 
of  an  inch  on  the  inner  sides  to  tilt  the  feet  on  to  their  outer  sides  ;  the  heels 
should  be  long  from  before  back  but  low  (high  heels  are  to  be  avoided  ;  they 
are  a  definite  cause  of  flat-feet  in  women,  though  it  is  hard  to  bring  convic- 
tion to  these  patients).  The  patient  must  be  drilled  in  standing  and  walking. 
The  position  in  standing  must  be  an  exaggeration  of  the  normal,  the  toes 
turned  slightly  inward,  and  when  feeling  tired  the  patient  should  rise  a 
few  times  on  the  toes,  and  occasionally  the  feet  should  be  inverted  for  a 
short  time  and  the  weight  taken  on  their  outer  sides.  In  walking  the  feet 
should  alternately  be  placed  completely  in  front  of  each  other  at  each 
stride  and  the  toes  turned  slightly  inward.  This  increases  the  stride  and 
improves  the  muscular  tone. 

In  addition  exercises  are  advisable  to  improve  the  muscles  of  the  calf 
and  legs. 

(a)  Rising  slowly  on  the  toes  and  heels  alternately  with  the  toes  inverted 
ten  to  fifty  times  morning  and  evening  (done  slowly). 

(6)  Sitting  with  the  legs  off  the  ground  and  circumducting  the  ankle- 
joint  slowly. 

(c)  Walking  slowly,  placing  each  foot  close  in  front  of  the  other  with 
the  toes  inverted  as  much  as  possible. 

Cold  baths,  massage,  resting  as  often  as  possible  with  the  feet  up,  and 
sitting  cross-legged  in  the  Turkish  fashion  will  also  be  of  assistance. 

Massage  is  especially  useful  where  there  is  spasm  of  the  peronei. 

"Where  the  arch  is  much  dropped  and  cannot  be  placed  in  position  by 
standing  on  tiptoe  or  manipulation  it  may  be  corrected  by  wrenching  under 
anaesthesia  and  placing  for  fourteen  to  twTenty-one  days  in  plaster,  after 
which  massage  and  exercises  are  gradually  commenced,  prolonged  standing 
being  avoided  for  about  six  weeks.  With  due  attention  most  cases  may 
be  cured  with  these  methods.  Where  the  patient  will  not  or  cannot  take 
this  trouble  alleviation  may  be  produced  by  wearing  a  Whitman's  steel 
brace  or  an  artificial  instep  fitted  in  the  boot.  This  plan  is  palliative  rather 
than  curative,  though  if  exercises  be  used  as  well  sometimes  good  may 
result. 

In  bad  cases  with  much  bony  deformity  and  ankylosis,  removal  of 
wedges  of  the  tarsus  or  head  of  the  astragalus  may  improve  the  appearance, 
but  is  not  likely  to  improve  the  function  to  any  marked  extent.  In  these 
cases  the  pain  often  ceases  and  the  main  trouble  is  the  shuffling  gait. 

(2)  Paralytic  Flat-foot.  When  resulting  from  poliomyelitis  the  condition 
is  usually  part  of  some  other  lesion,  as  calcaneo-valgus  The  coldness,  bad 
circulation  and  wasting  of  the  limb,  and  the  ease  with  which  the  arch  is 
restored  by  manipulation  render  diagnosis  easy  Treatment  will  be  on  the 
lines  described  for  T-calcaneus. 

(3)  Traumatic  Flat-foot.  This  results  from  falls  on  the  feet,  tearing  the 
plantar  ligaments,  fracturing  the  os  calcis,  astragalus,  &c,  or  as  the  result 
of  badly  set  fractures  at  the  lower  end  of  the  tibia  of  the  Pott's  type. 

The  condition  is  to  be  avoided  by  placing  the  part  in  good  position  with 


DIAGNOSIS  OF  THE   VARIETIES  OF  CLUB-FOOT  549 

the  arch  over-corrected  at  the  outset  in  a  divided  plaster-case,  and  not 
allowing  weight  to  be  taken  on  the  foot  for  sometime,  meanwhile  retaining 
the  arch  with  a  Whitman's  brace.  Where  the  deformity  is  actually  present 
the  same  brace  may  help  the  patient  :  removal  of  wedges  of  bone  is  not 
likely  to  be  of  much  good  as  regards  function.  Where  the  deformity  is  due 
to  a  badly  set  Pott's  fracture  the  malposition  is  really  in  the  leg  just  above 
the  foot,  and  may  be  improved  in  suitable  cases  by  a  supra-malleolar  osteo- 
tomy and  wearing  a  walking  instrument  with  irons  to  the  knee  and  a  valgus 
T-strap  for  some  months  afterwards. 

(4)  Gonorrheal  Flat-foot.  This  is  distinguished  by  the  acute  onset 
with  tenderness,  swelling,  and  redness  about  the  tarsus  and  sole  and  the 
presence  of  urethritis. 

Treatment.  The  patient  must  be  kept  off  the  feet  for  some  time,  the 
foot  in  correct  position  in  a  divided  plaster  and  the  urethritis  treated, 
vaccines  being  also  administered.  When  the  acute  changes  have  subsided 
treatment  is  on  the  lines  for  static  deformity. 

(e)  Hystekical  Talipes.  The  deformity  is  usually  equinus,  less  often 
equino-varus. 

The  condition  resembles  the  congenital  type,  in  that  there  is  no  muscular 
wasting  or  paralysis  or  degeneration  in  the  earlier  stages,  nor  is  there  the 
gross  spasm  found  in  spastic  cases  ;  but  originating  in  adolescent  life  as 
a  pure  equinus  (usually),  and  there  being  no  deformity  of  bones  or  liga- 
ments, distinguish  from  the  congenital  form. 

Treatment  is  difficult  unless  the  patient  can  be  persuaded  that  there  is 
nothing  the  matter,  since,  if  left,  the  contracture  will  become  permanent 
just  as  in  the  other  varieties  and  deformity  gradually  grow  worse.  Active 
treatment  of  the  foot,  by  centring  the  patient's  attention  there,  will  only 
make  matters  worse. 

Diagnosis  of  Talipes  with  regard  to  Cause.  Cases  of  spastic  paralysis  can 
be  separated  shortly,  by  the  increased  reflexes  of  the  affected  limbs,  by  the 
condition  being  bilateral  and  usually  a  pure  equinus,  by  the  rigidity  not 
only  of  the  feet  but  of  the  rest  of  the  legs — the  hamstrings  and  adductors 
being  contracted — and  often  by  mental  deficiency  when  due  to  cerebral 
birth  lesions  or  signs  of  Pott's  disease  or  spina  bifida. 

The  cases  due  to  injuries  or  infection  are  usually  easily  separated  from 
the  history,  and  there  remain  to  be  distinguished  the  congenital  cases  and 
those  due  to  flaccid  paralysis.  Congenital  cases  date  from  birth,  while 
paralytic  cases  usually  commence  in  the  first  three  years,  as  a  rule  with 
widespread  paralysis  of  the  lower  extremities.  Congenital  cases  are  often 
bilateral  and  usually  equal  and  symmetrical,  though  there  may  be  equino- 
varus  of  one  foot  with  calcaneus  of  the  other,  while  in  paralytic  cases  often 
only  one  foot  is  affected,  and  if  both  are  deformed  one  is  usually  worse  than 
the  other.  The  circulation  is  poor  in  paralytic  cases,  the  limb  being  blue 
and  cold,  while  wasting  is  much  more  evident  in  these  cases,  and  there  is  the 
reaction  of  degeneration  of  muscles.  Growth  of  the  limb  is  deficient 
in  paralytic  cases  but  not  in  the  congenital  variety,  and  the  creases  on 


A  TEXTBOOK  OF  SURGERY 

the  sole  described  in  the  congenital  cases  are  Dot  found  in  those  due  to 
paralysis. 

Painful  Hi  1 1  (ossification  of  the  plantai  Fascia).  Calcification  of  the 
posterior  part  of  the  plantar  fascia  as  it  Bprings  from  the  posterior  tubercle 
of  the  under-surface  of  the  os  calcis  will  form  a  spur  in  this  position  and 
cause  great  pain  in  walking.  There  is  often  a  history  of  gonorrhoea  and 
repeated  injury  (as  in  stamping  the  heel  repeatedly  in  some  occupation). 
Unless  a  radiograph  be  taken  the  condition  is  likely  to  be  mistaken  for 
the  painful  heel  of  early  flat-foot,  though  occasionally  the  projection  can 
actually  be  felt.  The  condition  is  cured  by  turning  back  a  flap  of  the  sole 
over  the  posterior  part  of  the  os  calcis  and  removing  the  spur  with  a 
chisel. 

Metatarsalgia  or  Mortons  Disease.  This  consists  of  attacks  of  pain  in 
the  anterior  part  of  the  foot  in  the  region  of  the  heads  of  the  fourth  and 
fifth  metatarsal  bones,  usually  in  the  middle-aged,  made  worse  by  walking 
and  relieved  by  rest  and  removing  the  boot. 

It  appears  to  be  due  to  sinking  of  the  transverse  arch  of  the  foot  and  is 
often  associated  with  flat-foot,  and  it  is  supposed  that  the  pain  is  due  to 
compression  of  the  interdigital  nerves  between  the  displaced  metatarsals 
or  between  the  latter  and  the  ground.  The  foot  is  broader  than  normal 
across  the  heads  of  the  metatarsals  owing  to  the  sinking  of  the  transverse 
arch,  and  pain  is  produced  by  pressing  these  together.  Considerable 
lameness  may  result. 

Treatment.  The  boots  should  be  wide  in  the  tread  so  as  not  to  compress 
the  ball  of  the  foot  but  closely  fitting  in  the  instep,  since  pressure  here 
relieves  the  pain.  The  boots  should  be  of  the  type  advised  for  flat-foot 
with  the  inner  side  of  the  sole  and  heel  thickened.  Exercises  as  for  flat- 
foot  should  be  practised,  and  also  flexion  and  extension  of  the  toes  at  the 
metatarso-phalangeal  joint.  If  this  treatment  is  not  sufficient  the  head 
of  the  displaced  metatarsal,  usually  the  fourth  (as  may  be  seen  in  a  radio- 
graph), should  be  excised  by  an  incision  from  the  dorsum. 

Affections  of  the  Mktatarso-phalangeal  Joint  of  the  Great  Toe. 
The  main  stress  of  walking  comes  on  this  joint,  and  for  its  size  it  is  subjected 
to  more  frequent  and  severe  strains  than  any  other  joint.  Hence  the 
frequent  appearance  of  gouty  and  other  arthritic  changes  here  ;  add  to 
this  the  distortion  it  is  made  to  endure  by  wearing  boots  of  the  usual 
type,  and  it  is  not  surprising  that  great  disability  often  occurs  in  this  joint. 

(a)  Hallux  Valgus.  In  this  deformity  the  great  toe  diverges  at  the 
metacarpophalangeal  joint  towards  the  mid-line  of  the  foot.  Varying 
degrees  of  the  deformity  exist  in  all  those  who  have  worn  boots,  unless  since 
childhood  footgear  with  a  straight  inner  border  has  been  worn.  Races 
who  go  barefoot  or  wear  sandals  are  exempt.  The  severe  cases  which 
need  treatment  result  from  the  crowding  together  of  the  toes  for  several 
years  in  boots  which  are  too  pointed  and  too  short.  It  should  be  noted 
t  h.t  if  pointed  toes  are  essential  to  the  mental  well-being  it  is  only  necessary 
to  >lope  the  boot  off  from  the  outer  side,  having  the  inner  side  straight  and 


HALLUX  VALGUS  AND  RIGIDUS 


551 


the  point  at  the  end  of  this.  It  is  having  the  point  of  the  boot  in  the  mid 
line  of  the  foot  which  works  the  mischief.  High  heels  accentuate  the 
deformity,  since  the  foot  tends  to  fall  inward  at  the  ankle  and  the  high 
heel  assists  in  levering  the  toe  outwards,  causing  both  splay-foot  and  hallux 
valgus.  The  result  of  forcing  the  toe  out  is  irritation  of  the  joint  and 
chronic  rheumatoid  changes  take  place,  the  head  of  the  metatarsal  is 
enlarged,  the  ligaments  on  the  outer  side  shortened,  and  the  deformity 
becomes  fixed.  A  bursa  often  forms  on  the  inner  side  of  the  head  of  the 
metatarsal,  which  is  likely  to  become  inflamed  and  may  suppurate.  As 
the  deformity  progresses  the  head  of  the  metatarsal  becomes  more  deformed 
till  the  toe  projects  out  across  the  foot  at  a  right  angle.  Hallux  valgus  is 
due  to  the  same  causes,  and  is  often  associated 
with  hammer-toe  and  ingrowing  toe-nail. 

Treatment.  Wearing  proper-shaped  boots  and 
using  exercises  as  for  flat-foot  prevents  the  de- 
formity increasing  in  the  slighter  cases :  if  the 
condition  is  marked  and  yet  the  toe  can  be  placed 
in  a  straight  line  with  the  metatarsal,  it  should  be 
kept  in  this  position  by  using  a  leather-sole  plate 
with  elastic  loops  attached  to  keep  the  toes  in  posi- 
tion ;  this  should  be  worn  day  and  night  for  a 
year,  when  the  deformity  should  remain  corrected, 
and  will  not  recur  if  correct  boots  are  worn.  Where 
the  toe  cannot  be  replaced  by  manipulation  opera- 
tion is  needed.  A  semi-circular  flap  is  turned  down 
over  the  joint  and  the  head  of  the  metacarpal 
excised :  the  tough  tissue  of  the  bursa  may  be 
used    as    a   flap    and    turned    between    the    bones 

(Mayo)  ;  this  will  help  to  prevent  ankylosis  taking  place.  The  patient 
can  walk  in  about  three  weeks,  wearing  corrective  apparatus  as  before; 
if  there  is  a  hammer-toe,  this  should  be  treated  at  the  same  time  and  on 
no  account  removed. 

(b)  Hallux  varus,  or  pigeon-toe,  seldom  causes  any  trouble  ;  if  it  inter- 
feres with  wearing  boots  it  may  be  wrenched  and  put  in  correct  position 
in  plaster. 

(c)  Hallux  Rigidus  and  Flexus.  This  is  found  in  young  persons  asso- 
ciated with  flat-foot :  there  is  a  painful  swelling  of  the  metacarpophalangeal 
joint  and  loss  of  dorsiflexion  (H.  rigidus)  ;  in  worse  cases  the  toe  is  held 
rigid  in  a  position  of  plantar  flexion  (H.  flexus).  Degenerative  changes 
occur  in  the  joint  and  walking  is  very  painful  and  difficult,  the  foot  being 
used  as  a  rigid  bar,  flexion  at  this  joint  being  impossible.  In  the  early 
stages  resting  the  foot  for  a  few  days  and  then  wearing  a  tint -foot  boot, 
with  massage  and  graduated  exercises,  may  cure.  If  this  plan  tails,  the  head 
of  the  metatarsal  should  be  excised  and  a  new  joint  formed  by  interposing 
a  flap  of  fat  and  fascia  (mere  excision  is  likely  to  be  followed  by  ankylosis 
in  these  cases  and  is  insufficient)  ;    if  this  fails  the  sole  of  the  boot  is  made 


Fig.  226.     Operation  for 

hallux  valgus,     a,  Skin 

flap,   h.  Line  of  resection 

of  head  of  metatarsal. 


a 


552  A  TEXTBOOK"  OF  SURGERY 

rigid  with  a  steel  plate,  the  patient  walking  with  completely  flat  foot 
which  is  awkward  but  relieves  the  pain. 

Hammer-toe.  In  this  deformity  there  is  hyperextension  of  the  first, 
flexion  of  the  second,  and  usually  hyperextension  of  the  terminal  phalanx. 

The  flexor  and  extensor  tendons  are  contracted  and  also  the  lateral  liga- 
ments of  the  first  interphalangeal  joint,  which  fix  the  deformity.     Corns 

appear  under  the  metatarsal  head  and  tip  of  the  last  phalanx,  and  over  the 
first  interphalangeal  joint.  The  deformity  is  most  usual  in  the  second  toe, 
which  is  often  overlong  and  crowded  up  by  pointed  boots  :  hallux  valgus 
and  ingrowing  toe-nail  are  commonly  associated  with  this  deformity,  the 
outward  thrust  of  the  great  toe  being  the  immediate  cause  of  the  bending  up 
of  the  second.  Hammer-toe  is  also  found  in  cases  of  pes  cavus,  when  all 
the  toes  may  be  affected.     The  corns  are  very  painful  and  may  suppurate. 

Treatment.  In  the  earlier  and  less  marked  degrees,  wearing  a  sole- 
plate  with  loops  to  correct  the  deformity  and  treatment  of  the  hallux  valgus 
or  pes  cavus  will  be  sufficient,  but  in  more  severe  cases  which  cannot  be 
reduced  by  manipulation  the  toe  must  be  corrected  by  operation.  The 
extensor  and  flexor  tendons  are  divided  subcutaneously,  as  well  as  the 
lateral  ligaments  of  the  first  interphalangeal  joint  (this  last  is  most  impor- 
tant). This  nearly  always  permits  of  correction,  but  should  tenotomies  be 
insufficient  the  distal  end  of  the  first  phalanx  may  be  removed  in  addition. 
Corrective  apparatus  as  before  must  be  worn  for  at  least  a  year  afterwards. 
When  associated  with  hallux  valgus  these  toes  should  never  be  removed, 
or  the  latter  condition  will  recur  in  an  aggravated  degree. 

Congenital  excess  in  the  number  of  toes  is  dealt  with  by  amputation 
as  needed.     Webbing  of  the  toes  needs  no  treatment. 

I  no  rowing  Toe-nail.  This  is  a  condition  of  pressure-ulceration  arising 
from  pressure  of  the  outer  border  of  the  great  against  the  second  toe  ;  the 
nail  is  pressed  into  the  soft  parts  and  causes  ulceration,  which  often  assumes 
the  hypeitrophic  form  with  large  granulations.  Much  pain  and  difficulty 
in  walking  may  result. 

In  the  milder  cases  wearing  normal  boots  and  other  treatment  directed 
to  the  hallux  valgus  may  result  in  cure  if  the  nail  be  pared  away  from  the 
tissue  on  which  it  was  pressing  and  the  ulcer  dusted  with  antiseptic  powder. 
Most  cases,  however,  come  up  in  a  more  aggravated  condition,  and  it  will 
be  best  to  remove  the  whole  nail  under  anaesthesia  and  dissect  away  its 
bed,  covering  the  raw  surface  with  a  Thiersch  skin-graft.  The  toe  without 
a  nail  is  just  as  good  as  before  and  return  of  the  trouble  is  effectively  checked. 

Paralyses  in  Children  and  their  Results.  It  will  be  seen  from  the 
preceding  sections  that,  apart  from  congenital  defects,  the  greater  bulk  of 
deformities  of  the  lower  limb  are  consequent  upon  paralyses,  which  fall  into 
two  groups  :  (a)  the  flaccid  or  spinal ;  (b)  the  spastic  or  upper-segment, 
usually  cerebral,  occasionally  from  spinal  cord  lesions  high  up. 

(a)  Acute  Anterior  Poliomyelitis  or  Infantile  I'amhjsis.  This  is  the 
great  cause  of  flaccid  paralysis  of  the  lower  limbs,  and  is  an  acute  infection 
of  the  grey  matter  of  the  cord,  leading  to  paralysis  of  the  muscles,  supplied 


PARALYSIS  IN  CHILDREN  553 

to  a  varying  degree.  Fever  may  or  may  not  be  present,  for  often  the 
paralysis  develops  without  other  signs.  The  lower  extremities  are  most 
usually  affected,  and  the  paralysis  is  much  more  widespread  at  first  than 
later,  i.e.  the  anterior  horn  cells  are  damaged  over  a  wide  area,  but  only 
destroyed  past  recovery  in  a  comparatively  small  zone.  Thus  at  the 
onset  the  whole  lower  limb  may  be  paralysed,  while  after  a  few  weeks  the 
only  paralyses  left  may  be  the  calf-muscles  or  foot-extensors  or  the  quad- 
riceps. In  addition  to  paralysis  the  nutrition  of  the  whole  limb  is  greatly 
impaired  by  want  of  use  and  loss  of  trophic  influence,  resulting  in  failure 
in  growth  of  the  bones.  Therefore  it  is  important  to  maintain  nutrition  as 
far  as  possible  (massage,  &c.)  while  recovery  is  taking  place.  In  addition 
to  the  temporary  paralysis  the  muscle  becomes  readily  overstretched  by 
the  action  of  antagonistic  muscles  and  gravity,  e.g.  the  dropping  of  the  feet 
in  paralysis  of  the  anterior  tibial  muscles,  and  when  the  opposing  muscles 
have  become  shortened  the  weakened  muscles  will  be  unable  to  regain 
their  former  length  and  lengthening  may  be  permanent.  Hence  care  is 
needed  to  prevent  such  overstretching  by  placing  the  limb  in  a  suitable 
position.  The  same  condition  results  from  the  weight  of  the  body  acting 
on  weakened  muscles,  and  it  is  necessary  to  support  these  by  the  help  of 
instruments  till  recovery  is  well  attained,  as  has  been  pointed  out  in  the 
treatment  of  paralytic  equinus,  by  tenotomy  of  the  tendo  Achillis  and  using 
a  \v;il king  instrument  with  toe-raising  spring.  Some  time  should  be  allowed 
to  elapse  under  such  treatment  before  tendon-grafting  is  employed,  as  it  may 
prove  unnecessary. 

When  paralytic  deformity  is  actually  present  it  must  be  corrected  by 
manipulation,  division  of  tendons,  ligaments,  &c,  and  correction  maintained 
by  the  help  of  apparatus,  such  that  use  of  the  limb  is  allowed  and  encouraged. 
The  earlier  a  limb  recovers  power  of  function  the  better  will  be  its  chance 
of  maintaining  its  growth,  and  in  the  lower  limb  it  is,  of  course,  most  impor- 
tant to  have  the  limbs  of  equal  length. 

Besides  retention  with  instruments,  removal  of  a  wide  area  of  skin  (Jones) 
on  the  paralysed  surface  of  the  limb  is  a  useful  method  of  maintaining 
correction  of  a  deformity,  e.g.  the  excision  of  an  oval  of  skin  from  the  dorsum 
of  the  foot  in  paralysis  of  the  anterior  tibial  muscles  rendering  a  walking- 
instrument  unnecessary. 

Tendon  and  muscle  transplantation  is  useful  where  recovery  beyond  a 
certain  point  is  impossible.  Thus  in  grave  defects  of  the  quadriceps  femoris 
the  sartorius  often  escapes,  and  this  muscle  or  part  of  the  hamstrings  may  be 
grafted  into  the  patella  to  prevent  the  knee  doubling  up.  Transplantation 
of  the  tibialis  anticus  into  the  peronei  or  vice  versa,  or  part  of  the  tendo 
Achillis  to  reinforce  either  of  the  former,  may  be  employed. 

Arthrodesis,  or  causing  ankylosis  of  a  joint  by  removal  of  articular 
cartilage,  may  be  done  for  flail  joints  ;  this  is  most  successful  at  the  ankle 
and  mid-tarsal  joints,  and  should  not  be  done  before  eight  years.  It  is 
often  a  question  whether  walking  apparatus  or  arthrodesis  is  to  be  advised, 
In  general,  where  pressure-sores  form  from  the  use  of  instruments  arthro- 


v.l  A   TKXTBOOK  OF  SURGERY 

desia  is  advisable,  or  where  two  joints  are  flail-like  one  should  be  fixed 
in  this  way. 

Nervt  anastomosis  has  hardly  come  up  to  expectations:  the  most 
suitable  place  is  one  popliteal  nerve  into  the  other  for  paralysis  nearly 
complete,  of  the  anterior  tibial  or  call  muscles. 

(b)  Spastic  Paralysis.  This  is  generally  due  to  cerebral  lesions,  some- 
times of  antenatal  date.  Pott's  disease  and  injuries  account  for  a  few  cases, 
when  a  laminectomy  and  removal  of  pressure  may  be  indicated. 

Cerebral  birth-palsies  result  usually  from  meningeal  haemorrhage  at 
birth  or  damage  to  the  brain  from  infective  conditions  later.  The  result 
may  be  a  hemiplegia,  but  more  usually  there  is  paralysis  of  the  arms  and 
legs  on  both  sides,  the  arms  recovering  to  a  large  degree  but  the  lower  limbs 
remaining  in  a  state  of  spastic  paralysis  known  as  Little's  disease.  Mental 
deficiency  is  common  ;  the  legs  are  rigid  in  extension  or  flexion  and  adduc- 
tion, the  knees  flexed,  the  toes  pointed  (plantar-flexion)  ;  the  deep  reflexes 
are  increased.  Sometimes  involuntary  irregular  movements  are  present 
(athetosis). 

Should  meningeal  haemorrhage  be  suspected  after  birth,  the  reasonable 
treatment  is  exploration  of  the  skull  and  removal  of  clots,  whereby  the 
whole  sequence  of  spastic  paralysis  may  be  avoided  ;  but  these  cases  are 
usually  brought  to  the  surgeon  after  a  few  years  with  the  condition  well 
developed. 

Treatment.  Forster's  operation  consists  in  dividing  alternate  sensory 
roots  in  the  sacral  and  lumbar  regions  after  laminectomy,  thus  cutting  off 
many  sensory  impulses  and  so  diminishing  the  spasm  :  good  results  are 
claimed.  In  addition,  or  without  this  plan,  operative  and  retentive  measures 
will  improve  the  condition.  The  adductors  are  excised,  the  hamstrings  and 
tendo  Achillis  lengthened,  and  the  patient  placed  on  a  frame  with  the  legs 
well  abducted  for  some  months,  and  after  this  in  a  walking  apparatus  he 
gradually  learns  to  walk.  Where  mental  power  is  very  deficient  no  treatment 
is  worth  attempting. 

OPERATIONS  ON  THE  FEET  AND  TOES 

Tenotomies,  (a)  The  Tibialis  Anticus.  This  may  be  cut  with  the 
posticus  in  the  modified  Phelps's  operation  through  the  open  wound,  but 
in  small  children  a  subcutaneous  tenotomy  is  sufficient.  The  division  is 
made  about  an  inch  from  its  insertion  and  above  the  tubercle  of  the  scaphoid. 
The  artery  lies  to  the  outer  side  but  separated  by  the  tendon  of  the  extensor 
hallucis.  The  tenotome  is  entered  from  the  outer  side,  and  the  tendon  which 
is  made  obvious  by  plantar-flexing  and  abducting  the  foot,  cut  through. 

(6)  The  tibialis  posticus  is  cut  about  one  inch  above  the  internal  mal- 
leolus. The  tenotome  is  entered  in  front  of  the  tendon  between  the  latter 
and  the  tibia,  where  it  sticks  firmly  ;  the  foot  is  dorsiflexed  and  the  tendon 
divided  by  cutting  backwards,  The  long  flexor  of  the  toes  is  often  divided 
as  well,  and  occasionally  the  vessels,  but  a  firm  bandage  will  prevent  bleeding. 

(c)  The  plantar  fascia  is  divided  about  an  inch  in  front  of  its  origin 


AMPUTATIONS  THROUGH  THE  FEET  555 

from  the  posterior  tubercle  of  the  os  calcis.  Having  rendered  it  tense  by 
(lovsirlexing  the  foot,  the  tenotome  is  passed  between  the  skin  and  the 
fascia  and  the  latter  divided  by  cutting  inwards.  The  slips  of  fascia  are 
felt  to  give  way  till  all  are  divided. 

(d)  The  tendo  Achillis  is  divided  half  an  inch  from  its  insertion  into  the 
os  calcis,  and  from  either  side ;  the  tenotome  is  entered  between  the  skin 
and  the  tendon  and  the  latter  divided  by  cutting  forward,  the  foot  being 


Fig.  227.  I,  Amputation  at  niid-tarsal  joint  (Chopart).  a,  Line  of  disarticulation. 
b,  Plantar  flap,  the  dorsal  flap  is  half  an  inch  lower  than  line  of  disarticulation. 
II,  Amputation  of  tarso- metatarsal  joint,  a,  Line  for  free  disarticulation  (Lisfranc) ; 
the  dorsal  flap  is  half  an  inch  below  this  (d),  the  plantar  flap,  b,  Modified  disarticula 
tion  cutting  through  internal  cuneiform  (Hey),  c,  Modified  disarticulation  through 
bone  of  second  metatarsal  (Skey). 

dorsiflexed  to  render  the  tendon  tense.  In  spastic  cases  lengthening  by  a 
Z-operation  should  be  done. 

(e)  The  peronei  may  be  divided  one  inch  above  the  external  malleolus 
by  inserting  a  tenotome  between  the  tendons  and  the  fibula  and  cutting 
backwards.  After  tenotomy  a  dressing  is  applied  and  the  foot  placed  in 
the  original  position  for  ten  days,  after  which  wrenching  is  done  and  the 
foot  now  placed  in  the  corrected  position  in  plaster  or  other  apparatus. 

Amputations,  (a)  At  the  Mid-tarsal  Joint  (Chopart).  The  line  of 
disarticulation  passes  between  the  os  calcis  and  astragalus  behind  and  the 
cuboid  and  scaphoid  in  front,  i.e.  between  the  tubercle  of  the  scaphoid 
and  the  mid-point  between  the  external  malleolus  and  the  base  of  the  fifth 
metatarsal  bone.  Marking  these  points  with  ringer  and  thumb  of  his  left 
hand,  with  its  dorsum  to  the  surgeon,  the  latter  cuts  the  plantar  flap, 


A  TEXTBOOK  OF  SVRCJKKY 


which  is  U-shaped,  its  base  being  at  the  point  mentioned  and  its  free  end 

at  the  Decks  of  the  metatarsal  bones.  This  Hap  is  dissected  up,  containing 
all  soft  parts  down  to  the  bone.  A  short  dorsal  flap  is  made  half  an  inch 
long,  also  down  to  the  hone,  joining  the  extremities  of  the  original  incision. 
Disarticulation  from  the  dorsum  is  easy.  The  extensor  tendons  are  sutured 
carefully  into  the  structures  of  the  plantar  flap  to  prevent  its  dropping  into 
an  equinus  position  and  enabling  the  patient  to  walk  on  the  flat  of  the  heel 
and  not  on  the  apex  of  the  stump,  it  this  precaution  lie  adopted  the  stump 
i-  excellent  and  an  ordinary  boot  can  he  worn  with  some  padding  in  the 
toes. 

(b)  Amputation  through  th  Tarso-metatarsal  Joint  (Lisfranc,  Hey,  Skey). 
This  is  also  by  long  plantar-flap,  the  base  being  at  a  line  joining  the  base  of 
the  tilth  metatarsal  and  a  point  one  inch  in  front  of  the  tubercle  of  the 
scaphoid.     Marking  these  points  as  before  with  the  finger  and  thumb,  the 

plantar-flap  reaching  to  the  heads  of  the  metatarsals  and 
including  all  structures  to  the  bone,  is  dissected  up  ;  a 
half-inch  dorsal  flap  is  then  made. 

Retracting  these  flaps,  the  three  outer  carpo-meta- 
carpal  joints  are  readily  opened  and  divided,  as  is  that 
of  the  first  from  the  inner  side. 

But  the  base  of  the  second  metacarpal  presents 
some  trouble  owing  to  the  strong  interarticular  liga- 
ment joining  this  to  the  internal  cuneiform.  If 
Lisfranc's  method  be  followed,  the  point  of  the  knife 
is  pushed  into  the  interval  between  the  internal  cunei- 
form and  the  base  of  the  second  metacarpal  with  its 
edge  upward,  and  by  levering  the  knife  upward  the 
ligament  is  divided.  Where  anatomical  knowledge  fails 
it  is  easy  to  saw  through  the  impacted  base  of  the 
second  metacarpal  (Skey)  or  to  cut  transversely  through 
the  internal  cuneiform  into  the  joint  between  the  middle 
cuneiform  and  the  second  metatarsal  (Hey).     The  scar 

will  be  on  the  dorsum  and  an  ordinary  boot  with  the  toes  padded  can  be 

worn. 

(c)  Amputation  of  the  Toes.  (1 )  The  smaller  toes  should  only  be  removed 
at  the  metatarso-phalangeal  joint ;  if  removed  lower  the  stump  will  project 
awkwardly  and  is  of  no  use.  The  racket  method  is  best  for  the  small  toes, 
the  handle  commencing  at  the  neck  of  the  metacarpal  and  the  loop  being 
on  a  level  with  the  web  of  the  toe.  The  soft  parts  are  separated  back  to  the 
joint,  which  is  further  back'  than  might  be  imagined  and  fully  an  inch 
behind  the  web  :  strongly  dorsiflexing  the  digit,  the  joint  is  opened  from 
tie-  plantar  surface.  Unless  the  position  of  the  joint  be  remembered  the 
two  last  phalanges  are  likely  to  be  removed  instead  of  the  entire  digit. 

In  the  case  of  the  little  toe  the  handle  of  the  racket  is  on  the  mesial 
side  of  the  metacarpal  bone  so  that  the  scar  is  out  of  the  way  of  lateral 
pressure. 


Fig.  228.  Amputa- 
tion of  great  toe  at 
metacarpo  -  phalan- 

■_'  .il  joint. 


AMPUTATION  OF  THE  GREAT  TOE         557 

(2)  The  Great  Toe.  The  last  phalanx  may  be  removed  by  similar  opera- 
tion to  that  used  for  the  fingers.  The  whole  toe  is  removed  at  the  metatarso- 
phalangeal joint  by  a  modified  racket  to  secure  a  larger  flap  for  covering 
the  large  head  of  the  metacarpal  and  ensuring  the  scar  being  on  the  dorsum. 

The  dorsal  incision  starts  at  the  neck  of  the  metacarpal  on  the  outer 
(fibular)  side  of  the  extensor  tendon  and  is  carried  down  parallel  with  this 
to  the  level  of  the  web  ;  at  this  level  it  is  carried  round  to  the  inner  aspect 
of  the  digit  and  thence  straight  back  to  its  starting-point.  The  soft  parts 
are  peeled  off  and  the  disarticulation  made  as  in  the  other  toes  :  the  sesa- 
moids and  attached  muscles  are  preserved. 

The  heads  of  the  metacarpals  should,  if  possible,  never  be  removed, 
especially  that  of  the  great  toe,  as  on  their  integrity  depends  much  of  the 
spring  of  the  foot.  The  great  or  other  toes  can  be  removed  with  their 
metacarpals  by  extending  the  handle  of  the  racket  up  to  the  carpo- metacarpal 
joint,  adding  a  small  transverse  incision  at  this  point  if  need  be.  The  base 
of  the  first  metatarsal  should  always  be  preserved  if  possible,  to  save  the 
insertion  of  the  peroneus  longus  and  tibialis  anticus. 


SECTION   III 

SURGERY   OF   THE   NERVOUS  SYSTEM 

AND  EAR 

CHAPTER  XV 

AFFECTIONS  OF  THE  SCALP,  SKULL,   BRAIN,  EAR   AND 
SPINAL  CORD 

The  Scalp — Injuries  :  Inflammations  :  Tumours. 

The  Cranium — Congenital  defects  :  Injuries  :  Simple  fractures  :  Compound 
fractures  :  Depressed  fractures  :  Operations  :  Fractures  of  the  base  of  the 
skull  :  Infections  of  the  cranium  :  Pyogenic  :  Syphilis  :  Xew  growths. 
The  Brain — General  considerations  :  Cere bro -cranial  topography  :  Cortical 
areas,  general  diagnosis  :  Methods  of  opening  the  skull :  Concussion  of  the  brain  : 
Cerebral  irritation  :  Acute  compression  of  the  brain  :  Intracranial  haemorrhage 
(Extradural,  intradural)  :  Laceration  of  the  brain  :  Penetrating  wounds  : 
Bullets  :  Intracranial  inflammation. 

The  Ear — anatomy,  relations,  and  diagnosis  :  The  external  ear  :  Foreign  bodies  : 
Inflammations  :  Tumours  :  The  middle  ear  :  Inflammations  :  Eustachian 
catarrh  :  Acute  otitis  media  :  Chronic  suppurative  otitis  :  Otosclerosis  :  Polypi  : 
( iaries  of  the  temporal  bone  :  Mastoiditis  :  Operation  for  inveterate  otitis  media 
and  its  complications  :  Intracranial  complications  of  otitis  media  :  Extra- 
dural abscess  :  Subdural  inflammations  :  Acute  and  chronic  lepto-meningitis  : 
Subdural  abscess  :  Thrombosis  of  intracranial  sinuses  :  The  lateral  sinus,  the 
cavernous  sinus  :  Encephalitis  :  Otitic  cerebral  abscess  and  cerebellar  abscess  : 
Other  cerebral  abscesses  :  Hernia  cerebri  :  Epilepsy  :  The  traumatic  neuroses  : 
Cerebral  tumours  :  Operations  :  Hydrocephalus. 

The  Spinal  Cord  :  Anatomy  :  Diagnosis  :  Laminectomy  :  Congenital  affections  : 
Injuries  of  the  spine  :  Fracture-dislocations  :  Injuries  of  the  cord  :  Compression 
myelitis  :  Tumours  of  the  cord. 

AFFECTIONS  OF  THE  SCALP 

The  scalp  proper  is  a  dense  structure  consisting  of  the  occipito-frontalis 
muscle  welded  firmly  by  the  tough  subcutaneous  tissue  to  the  hair-bearing 
portion  of  the  skin.  It  is  attached  firmly  in  front  and  behind  to  the  supra- 
orbital ridge  and  the  superior  curved  line  of  the  occiput  respectively,  and 
more  loosely  at  the  sides  to  the  temporal  ridge.  The  attachment  to  the 
pericranium  is  by  loose  areolar  tissue  permitting  of  easy  separation  in  this 
plane,  and  allowing  a  free  passage  of  exudation  in  all  directions  between  the 
scalp  and  the  pericranium.  The  vessels  enter  the  scalp  at  the  front,  back  and 
sides  :  hence  large  flaps  can  be  raised  at  operation  or  by  accidents  without 
risk  of  sloughing,  the  blood-supply  being  extremely  good.     The  periosteum 

558 


H,EMATOM,E  OF  THE  SCALP 


559 


of  the  cranium  (pericranium)  has  no  power  of  forming  new  bone,  nor  does 
it  carry  any  appreciable  blood-supply  to  the  skull,  and  is  attached  firmly 
to  the  subjacent  bone  only  at  the  suture  lines  so  that  it  may  be  removed 
over  large  areas  without  causing  necrosis  of  the  skull,  while  effusion  under 
it  tends  to  assume  the  shape  of  the  bone  over  which  the  injury  occurs,  being 
bounded  by  the  sutures. 

Injuries  of  the  Scalp.  Both  contusions  and  penetrating  wounds 
may  occur. 

(a)  Contusions  of  the  scalp  (called  cephal-hsematoma  if  there  is  much 
effusion  of  blood)  are  the  result  of  falls  and  blows  on  the  head,  and  are  of 


C-- 


Fig.  229.     Effusions  and  hamartomas  of  the  scalp  (diagrammatic  section).     '/.  In 
the  scalp  proper  (small  and  localized),     b,  In  the  "  dangerous  area  "  (spreading 
over  the  cranium),     c,  Subperiosteal,    localized  by  the  sutures,     e,  Cranial  apo- 
neurosis.   /,  Pericranium,     g,  Skull. 

trifling  importance  themselves  but  may  be  associated  with  serious  damage 
to  the  underlying  brain.  Three  varieties  are  distinguished  according  as 
the  blood  is  effused  (1)  into  the  scalp,  (2)  between  the  scalp  and  pericranium, 
or  (3)  under  the  latter. 

(1)  Hsematoma  of  the  scalp  proper  is  the  common  condition,  and  owing 
to  the  density  of  the  tissues  is  necessarily  small,  circumscribed,  and  movable 
on  the  deeper  structures. 

(2)  Where  the  effusion  of  blood  is  subaponeurotic  the  whole  scalp  is 
lifted  off  the  cranium  and  is  felt  to  lie  on  a  fluctuating  mass  extending  from 
glabella  to  occiput  and  laterally  to  the  temporal  ridges. 

(3)  A  subpericranial  hsematoma  is  limited  by  the  attachment  of  the 
periosteum  at  the  sutures,  is  usually  found  on  the  parietal  bones  of  infants. 
and  is  of  oblong  shape. 

Diagnosis.  Care  must  be  taken  to  note  any  signs  of  concussion  or 
compression  of  the  brain,  which  may  complicate  such  a  hsematoma,  but 
the  condition  most  likely  to  be  confused  with  a  large  hsematonia  of  the 


A  TEXTBOOK  OF  SURGERY 

scalp  is  a  depressed  fracture  of  the  skull,  which  is  a  serious  matter  and 
should  not  be  missed,  [n  the  early  stages  of  a  hsematoma  it  is  easy  by  firmly 
pressing  into  the  swelling  to  feel  the  rounded  outline  of  the  skull,  if  the 
latter  be  not  fractured.  Later,  when  clotting  lias  taken  place,  the  outer 
edge  of  the  partially  clotted  hsematoma  feels  bard  and  raised  while  the 
central,  softer  part  resembles  a  depression.  Firm  pressure  will,  however, 
force  the  exudate  out  of  the  hard  edge,  showing  that  it  is  not  of  bony  consis- 
tency, and  the  unbroken  surface  of  the  skull  can  as  a  rule  be  felt  on  further 
palpation  through  the  hsematoma.  Should  there  be  the  slightest  doubt 
in  the  surgeon's  mind  as  to  the  presence  of  a  depressed  fracture,  he  should 
have  no  hesitation  in  turning  back  a  flap  of  scalp  and  examining  the  bone. 
A  depressed  fracture,  if  neglected,  will  almost  certainly  lead  to  serious 
consequences,  whereas"  opening  a  hsematoma,  if  done  with  aseptic  precau- 
tions, will  rather  expedite  than  delay  healing. 

Treatment.  Application  of  cooling  lotion  is  the  usual  method  :  if  ab- 
sorption of  clot  be  long  delayed  it  is  as  well  to  open  the  swelling  and  turn  out 
the  blood,  as  suppuration  is  always  liable  to  take  place  in  a  hsematoma. 

(b)  Wounds  of  the  Scalp.  These  may  be  clean-cut,  lacerated,  or  punc- 
tured. From  a  medico-legal  standpoint  it  is  important  to  realize  that  a 
clean-cut  wound  may  be  caused  by  a  blow  from  a  blunt  weapon  or  a  fall 
on  a  smooth  surface. 

Where  the  wound  does  not  penetrate  the  aponeurosis,  i.e.  is  confined  to 
the  scalp  proper,  the  condition  is  trifling,  but  if  the  whole  scalp  is  divided 
so  that  the  subaponeurotic  space  is  opened  up  there  is  a  chance  that  this 
"  dangerous  area  "  may  be  infected  and  suppuration  spread  over  the  surface 
of  the  cranium,  till  the  whole  scalp  rests  on  a  bed  of  pus.  Where  the  whole 
thickness  of  the  scalp  is  divided  the  wound  gapes  considerably.  More 
important  still  is  it  to  note  whether  there  be  no  depressed  or  punctured 
fracture  under  such  a  scalp  wound,  and  such  wounds  should,  after  thorough 
cleansing,  be  explored  with  both  sterilized  ringer  and  fine  probe  till  the 
matter  is  absolutely  certain.  The  finger  most  easily  detects  gross  depres- 
sion, while  the  use  of  a  fine  probe  or  blunt  dissector  is  needed  to  detect  small 
punctures  such  as  may  be  made  with  the  blade  of  a  knife. 

Treatment.  The  scalp  should  be  shaved  and  sterilized  writh  iodine 
solution,  badly  bruised  parts  being  excised,  and  sutured  with  interrupted 
sutures.  Bleeding  vessels  are  usually  controlled  readily  by  sutures,  but 
should  it  be  necessary  to  tie  vessels  fine  silk  should  be  used,  as  catgut  will 
not  get  a  good  grip  on  the  tough  scalp. 

Where  the  scalp  has  been  almost  completely  torn  off,  as  in  "  scalping 
accidents,"  which  usually  happen  from  revolving  machinery  catching  the 
hair  of  women,  the  resulting  flaps  will  usually  heal  in  place  if  cleaned  and 
replaced,  even  if  only  a  narrow7  pedicle  is  left  to  maintain  the  circulation. 

If  the  scalp  is  completely  torn  off  skin-grafting  will  be  necessary. 

Acute  Inflammations  of  the  Scalp.  These  are  due  to  infection  with 
pyogenic  organisms,  usually  inoculated  through  some  scratch  or  abrasion, 
and  may  be  localized  or  diffuse. 


INFECTIONS  OF  THE  SCALP  561 

(a)  Erysipelas  and  cellulitis  may  be  due  to  local  infection  or,  especially 
in  the  former  instance,  result  by  spread  from  neighbouring  parts,  such  as 
the  face,  nasal  sinuses,  &c.  Clinically  there  is  little  distinction  between 
the  two  infections  in  this  situation,  as  the  edge  is  not  well  defined,  nor  does 
the  skin  of  the  scalp  show  the  scarlet  blush  of  erysipelas  but  is  tender, 
boggy,  and  cedematous,  while  the  constitutional  signs  are  well  marked. 
There  is  some  risk  of  the  infection  spreading  along  emissary  veins  to 
the  meninges  and  ending  fatally,  while  an  cedematous  swelling  of  the 
scalp  may  indicate  mischief  in  or  below  the  skull  (see  Pott's  Puffv 
Tumour,  p.  575). 

Treatment.  Where  consecutive  to  erysipelas  of  neighbouring  parts  the 
treatment  is  as  for  that  condition.  But  where  following  local  injury, 
especially  punctured  wounds,  the  wound  should  be  freely  enlarged  and  the 
pericranium  examined.  If  the  latter  be  found  raised,  leaving  the  skull 
bare,  the  question  of  trephining  the  latter  must  be  considered,  and  carried 
out  if  it  be  suspected  that  suppuration  is  taking  place  inside  the  cranium 
(see  Intracranial  Suppuration,  pp.  620-630). 

(b)  Localized  acute  infection  or  abscess  may  occur  in  the  (1)  scalp 
proper,  (2)  in  the  subaponeurotic  area,  or  (3)  under  the  pericranium. 

( 1 )  Abscesses  in  the  scalp  proper  may  result  from  infection  of  hair  follicles, 
pediculosis  or  abrasions,  and  is  soon  cured  by  opening  and  fomenting. 

(2)  Diffuse  suppuration  below  the  scalp  in  the  "  dangerous  area  "  is 
usually  due  to  a  scalp-wound  affecting  this  area,  and  is  recognized  as  a 
tender,  boggy  swelling  occupying  the  whole  scalp  from  brow  to  occiput, 
reaching  down  to  the  ears,  with  general  signs  of  pyogenic  infection. 

Treatment.  The  collection  is  opened  by  vertical  incisions  at  the  four 
corners,  thus  avoiding  the  main  vessels  ;  the  pus  is  pressed  out  and  drainage- 
tubes  inserted,  and  irrigation  with  peroxide  of  hydrogen  employed  till  the 
discharge  becomes  clear,  when  the  tubes  are  removed. 

(3)  Suppuration  under  the  pericranium  marks  out  the  shape  of  the  under- 
lying bone,  and  usually  follows  disease  of  this  (see  Suppuration  of  the 
Cranium,  p.  575). 

Of  chronic  infections  gummata  in  tertiary  syphilis  are  common,  and 
may  affect  the  scalp  or  spread  from  the  underlying  bone,  bursting  on 
the  surface  and  giving  rise  to  the  usual  punched-out,  chronic  ulcers. 

New  Growths  of  the  Scalp.  These  are:  (1)  epithelial,  (2)  fibrous 
and  sarcomatous,  (3)  vascular. 

(1)  Of  innocent  epithelial  tumours,  warts  or  papillomas,  sebaceous 
cysts,  and  dermoids  are  common,  and  resemble  in  pathology  and  treatment 
such  tumours  elsewhere. 

Dermoids  are  found  at  the  outer  angle  of  the  orbit,  in  the  temporal 
region,  and  at  the  root  of  the  nose.  In  some  cases  in  the  latter  situations 
the  bone  under  the  dermoid  is  hollowed  out.  suggesting  a  previous  con- 
nexion with  the  primitive  vesicles  of  the  brain,  and  they  may.  in  fact,  be 
attached  to  the  dura  mater  through  a  defect  in  the  cranium.  These  tumours 
are  readily  cured  by  excision, 
i  36 


562  A  TEXTBOOK  OF  SURGERY 

Of  malignant  epithelial  tumours: 

(n)  Rodent  ulcer  is  uncommon  except  as  an  extension  from  the  face  or 
ear. 

(b)  Epithelioma  is  not  uncommon,  presenting  the  usual  signs  of  a  callous 
ulcer  with  everted  edges  and  infiltrated  base,  while  there  is  rapid  secondary 
enlargement  of  lymph-nodes — the  occipital  from  growths  of  the  back,  the 
mastoid  from  hack  and  sides,  and  the  parotid  and  pre-auricular  groups  from 
the  front  and  sides  of  the  scalp. 

Such  epitheliomas  often  originate  in  lupoid  scars  or  cicatrices  of  burns 
and  in  irritated  warts  or  sebaceous  cysts. 

(c)  Sebaceous  carcinoma  or  adenoma  is  likely  to  start  in  degenerating 
sebaceous  cysts,  and  is  found  as  a  fungating  mass  apparently  consisting  of 
granulation-tissue,  which  gradually  spreads  over  the  scalp.  Sections, 
however,  show  that  the  mass  is  made  up  of  invading  columns  of  epithelial 
cells  resembling  those  found  in  rodent  ulcer.  Somewhat  similar  granulation 
tumours,  however,  also  result  from  neglect  of  suppurating  foci  on  the  scalp. 
The  malignancy  of  sebaceous  cancer  is  not  great,  and  free  removal,  followed 
by  skin-grafting,  should  cure  the  condition.  The  outlook  in  cases  of  epithe- 
lioma is  less  hopeful.  Free  removal  of  the  tumour,  including  underlying 
skull  if  adherent  and  removal  of  the  lymph-nodes  into  which  the  part 
drains,  will  be  needed  to  ensure  a  reasonable  prospect  of  cure. 

(2)  Coxxective-tissue  Tumours,  (a)  Fibroma  is  sometimes  found  as 
localized  thickening  of  the  scalp. 

(b)  S  ireomas  of  varying  types  occur,  which  may  become  large  tumours, 
possibly  pulsating  or  fungating  through  the  skin.  In  the  early  stages 
they  are  movable  on  the  cranium,  and  so  can  be  distinguished  from  the 
more  common  sarcomas  growing  from  the  cranium  or  dura  mater.  Glan- 
dular infection  is  unusual,  and  treatment  consists  in  free  removal,  closing 
the  gap  with  skin-grafts  or  flaps,  and  use  of  X-rays. 

(3)  Vascular  Tumours  of  the  Scalp,  (a)  Ncevi,  both  capillary  and 
cavernous,  are  common  on  the  scalp.  A  rather  common  situation  is  over 
the  anterior  fontanelle;  in  which  situation  pulsation  is  noted.  As  excision 
or  electrolysis  might  lead  to  injury  of  the  dura  mater,  it  is  best  to  leave 
such  cases  till  the  fontanelle  has  closed  or  treat  with  solid  carbon  dioxide. 

(6)  Cirsoid  aneurysm  or  plexiform-angeioma  is  a  rare  form  of  tumour 
and  seldom  found  except  on  the  scalp.  The  tumour  consists  of  a  mass  of 
dilated  and  tortuous  arteries  with  thin  walls  or  spaces  into  which  arteries 
open  without  intervention  of  capillaries.  The  formation  usually  originates 
in  the  temporal  region  and  spreads  over  the  whole  scalp.  Clinically  the 
tumour  i-  seen  to  consist  of  tortuous  pulsating  vessels,  shining  blue  through 
the  skin,  and  is  easily  emptied  by  pressure  but  rapidly  refills  again.  The 
skin  over  the  mass  becomes  thin,  ulcerates,  and  finally  gives  way,  leading  to 
severe  haemorrhage.  These  growths  are  locally  invading,  and  thus  malig- 
nant, though  of  very  slow  growth.     (Fig.  230.) 

Treatment  is  difficult  and  often  unsatisfactory. 

While  the  tumour  is  still  small  it  may  be  excised,  and  to  avoid  bleeding 


CIRSOID  ANEURYSM 


563 


during  the  operation  a  rubber  tourniquet  may  be  placed  round  the  skull 
from  brow  to  occiput.  The  periphery  is  carefully  dissected  and  vessels 
tied  as  they  lead  to  the  growth  ;  after  excision  the  raw  surface  will  need 
skin-grafting:. 

Where  the  tumour  is  larger  this  method  may  be  impracticable,  and  it 
will  be  better  to  tie  all  the  large  vessels  going  to  the  growth  and  electrolyze 


Fig,  230.     Cirsoid  aneurysm  of  the  frontal  region,  invading  the  right  orbit  and 
depressing  the  eyeball.     (Mr.  Hutchinson's  case.) 

the  mass  in  order  to  promote  clotting  and  fibrosis.  A  plan  worth  trying  in 
severe  cases  is  the  injection  of  boiling  water  into  the  external  carotid  artery 
(a  measure  very  successful  in  reducing  sarcomatous  growths),  at  the  same 
time  tying  the  anastomotic  vessels.  This  should  produce  much  fibrosis 
in  the  mass  :  heavy  doses  of  X-rays  and  electrolysis  may  be  used  in  com- 
bination with  these  procedures. 

(c)  Cephal-h(B)natoca>le  is  a  rare  tumour  formed  of  venous  spaces  in 
the  scalp  communicating  with  the  longitudinal  sinus  through  a  hole  in  the 
skull.  It  will  be  found  as  a  bluish,  compressible  tumour  in  the  mid-line 
with  an  impulse  on  coughing,  the  hole  in  the  skull  being  palpable  on  reduction 
of  the  mass. 


564  A  TEXTBOOK  OF  SURGERY 

Treatment.  The  tumour  is  explored  and  the  vessels  that  connect  with 
the  sinus  tied,  or  if  the  communication  is  very  free  the  sinus  may  be  tied 
in  front  and  behind  the  tumour. 

General  Diagnosis  of  Tumours  presenting  in  the  Scalp.  These  maybe 
derived  from  the  scalp,  the  cranium,  or  from  inside  the  cranium. 

(a)  'rumours  of  the  scalp  proper  will  be  at  first  movable  on  the  skull, 
becoming  later  adherent  ;  pulsation  is  common,  but  an  impulse  on  coughing 
not  often  present  unless  there  is  free  communication  with  the  intracranial 
blood-vessels. 

(b)  Tumours  of  cranial  origin  will  be  fixed  to  the  latter  from  the  onset ; 
there  may  be  pulsation  but  no  impulse  on  coughing,  and  no  aperture  will 
be  felt  in  the  skull. 

(c)  When  derived  from  inside  the  cranium  there  will  often  be  an  aperture 
in  the  latter  through  which  the  tumour  appears,  and  through  which  it  may 
be  more  or  less  reducible  ;  an  impulse  on  coughing  and  pulsation  are  usual 
in  the  cystic  conditions  such  as  meningoccele,  hernia  cerebri,  traumatic  cephal- 
hvdroccele,  &c,  but  in  the  more  solid  growths  (sarcomas),  though  pulsation 
is  present  as  a  rule,  an  impulse  on  coughing  may  be  absent,  as  in  sarcoma 
of  the  dura.  The  last  example  may  not  be  easy  to  distinguish  from  a 
similar  tumour  growing  from  the  cranium,  except  that  in  the  former  con- 
dition there  will  often  be  signs  of  raised  intracranial  pressure  such  as  head- 
ache, vomiting  and  optic  neuritis,  before  the  external  tumour  appears. 

AFFECTIONS  OF  THE  CRANIUM 

Ax  atom  v.  The  osseous  box  containing  the  brain,  meninges,  vessels, 
and  origins  of  the  cranial  nerves  consists  of  the  upper  rounded,  dome-like 
vertex,  practically  devoid  of  apertures  and  so  dense  and  resistant  to  violence 
that  it  is  seldom  fractured  unless  broken  inwards  (depressed  fracture), 
and  the  lower  part  or  base,  which  is  irregular  in  shape,  containing  many 
apertures  for  nerves  and  vessels  and  places  where  the  sutures  do  not  fit 
accurately,  and  moreover,  being  made  of  more  spongy  bone,  is  hence  liable 
to  split  in  various  directions,  usually  from  indirect  violence.  Of  the  three 
fossae  into  which  the  base  is  divided,  the  anterior  lies  above  the  orbit,  nasal 
cavity,  and  frontal  sinus,  the  floor  being  thin  and  readily  penetrated  by  a 
pointed  object,  such  as  a  stick  or  umbrella,  introduced  through  the  orbit 
or  nasal  fossa. 

The  middle  fossa  lies  above  the  naso-pharynx  and  temporal  region,  while 
the  posterior  fossa,  which  is  below  the  tentorium,  lies  above  the  pharynx 
and  occipital  region.  The  veins  of  the  scalp  communicate  with  the  intra- 
cranial sinuses  by  means  of  certain  emissary  veins,  which  account  for  the 
spread  of  infection  through  the  cranial  wall  in  either  direction. 

Amongst  t  hese  emissary  veins  are  the  parietal,  leading  to  the  longitudinal 
sinus,  the  mastoid  and  posterior  condylar,  leading  to  the  sigmoid  (lateral) 
sinus  ;  the  facial  and  frontal  veins  communicate  via  the  ophthalmic  vein 
with  the  cavernous  sinus.  In  addition  the  diploic  veins  of  the  skull  com- 
municate with  those  of  the  scalp  and  drain  into  the  intracranial  sinuses. 


MENINGOCELE..  ENCEPHALOCCELE,  HYDRENCEPHALOCCELE  565 

Congenital  Defects  of  the  Cranium.  (1)  Meningocoele,  Encephaloccele, 
Hydrencephalocoele.  These  defects  consist  of  a  protrusion  of  the  contents 
of  the  cranium  through  a  space  in  the  latter,  so  that  they  may  be  regarded 
as  congenital  varieties  of  hernia  cerebri. 

These  affections  appear  to  be  due  primarily  to  congenital  defects  in  the 
drainage  system  of  the  brain,  so  that  cerebro-spinal  fluid  collects  in  the 
ventricles,  especially  the  fourth,  and  in  the  subarachnoid  space,  causing  in- 
crease of  intracranial  pressure,  and  associated  with  this  there  is  a  failure  to 
develop  on  the  part  of  the  bony  cranium  and  the  distended  meninges  or  brain 
and  meninges  protrude.  The  usual  situation  for  these  protrusions  is  in  the 
occipital  region  from  failure  of  the  four  parts  of  the  supra-occipital  bone  to 
unite,  less  often  at  the  root  of  the  nose  between  the  frontal  and  nasal  bones, 
occasionally  through  the  fontanelles  or  the  base  of  the  skull  into  the  pharynx. 
Where  the  protrusion  is  of  meninges  only  it  is  called  a  meningocoele,  when 
of  brain  and  membranes  an  encephaloccele,  when  of  brain  dilated  by  excess 
of  fluid  in  the  ventricles  a  hydrencephalocoele.  In  most  instances  the 
apparent  meningocceles  through  the  occipital  bone  are  really  hydrencephalo- 
coeles,  the  thinned  roof  of  the  fourth  ventricle  being  expanded  and  hardly 
to  be  distinguished  from  the  overlying  meninges. 

Signs.  There  will  be  a  congenital  swelling  over  the  occiput,  root  of  the 
nose,  side  of  the  skull,  or  in  the  pharynx— which  may  be  very  large,  some- 
times as  big  as  the  head,  possibly  pedunculated,  in  other  instances  smaller 
and  sessile.  The  tumour  is  partly  reducible  with  an  impulse  on  coughing. 
A  pure  meningocoele  is  translucent  and  does  not  pulsate,  whereas  if 
brain-matter  is  present  the  swelling  is  opaque  and  pulsates  (note  the 
thin  hydrencephalocoele  of  the  fourth  ventricle  is  translucent).  At  the 
root  of  the  tumour  a  hole  can  be  felt  in  the  cranium.  Pressure  on  the 
swelling  may  cause  convulsions.  The  prognosis  is  bad  in  most  instances 
owing  to  the  underlying  cerebral  effects,  and  such  infants  are  often  still- 
born or  become  idiots  if  arriving  at  maturity  :  further,  the  cyst  is  liable 
to  enlarge  and  burst,  leading  to  death  from  infective  meningitis  ;  while  in 
a  number  of  instances  thinning  of  the  brain  from  internal  hydrocephalus  is 
present. 

Treatment.  Obvious  encephalocceles  and  hydrencephalocceles  are  best 
let  alone.  Meningocceles  may  be  dissected  away — the  pedicle,  if  small, 
being  tied,  while  if  larger  this  is  sutured  and  muscle  and  aponeurosis  from 
the  neighbourhood  brought  across  to  fill  the  gap.  If  the  case  really  is  one 
of  hydrencephalocoele  the  operation  is  not  likely  to  be  of  any  use.  Pure 
meningocceles  may  be  cured  naturally,  being  cut  off  from  the  cranial  cavity 
by  growth  of  the  skull  and  persisting  as  cysts  lying  over  depressed  areas 
of  the  skull,  a  variety  of  dermoid  mentioned  in  the  last  section. 

(2)  Ossification  of  the  skull  may  be  incomplete  (aplasia  cranii  congenita), 
in  which  case  there  are  soft  areas  of  the  skull.  The  cause  is  unknown, 
and  care  of  such  infants  is  needed  t<>  prevent  injuries  to  the  brain. 

(3)  Microcephaly,  or  smallness  of  the  cranium  from  too  early  union  of 
the  sutures,  is  the  result  of  insufficient  development  of  the  brain  of  congenital 


566  A  TEXTBOOK  OF  SURGERY 

origin,  and  hence  the  operation  of  craniotomy  <>r  making  new  sutures  to 
allow  of  growth  is  of  no  use. 

Injuries  of  the  Cranium.  (a)  Contusions  of  the  Skull.  Though  of 
slight  importance  in  themselves,  contusions  of  the  cranium  may  be  asso- 
ciated with  or  lead  to  serious  results,  and  should  not  be  regarded  lightly. 
Such  complications  are  : 

(1)  The  dura  may  be  separated  from  the  skull  and  the  meningeal  vessels 
torn,  leading  to  extradural  haemorrhage  and  pressure  on  the  brain  (see 
Cerebral  Compression  and  Middle  Meningeal  Haemorrhage,  pp.  590.  592). 

(2  Laceration  and  bruising  of  the  brain  may  be  caused  without  fracture 
of  the  skull  (see  Injuries  of  the  Brain,  p.  596). 

(3)  Various  inflammatory  diseases  may  be  initiated,  especially  in  the 
subjects  of  some  general  disease  such  as  syphilis  ;  or  acute  inflammation 
of  the  bone  may  follow  by  invasion  of  the  damaged  spot  with  pyogenic 
organisms,  leading  to  abscess-formation  beneath  the  pericranium  or  necrosis 
of  the  bone  with  extradural  abscess.  Again,  chronic  hypertrophy  of  the 
bone  may  take  place,  causing  pressure  on  the  brain  with  constant  headache, 
epilepsy,  &c. 

(4)  Traumatic  neurasthenia  often  develops  after  severe  contusions  with 
concussion  of  the  brain. 

(b)  Fractures  of  the  Skull.  These  are  by  common  consent  divided  into 
(a)  those  of  the  vault,  which  for  diagnosis  can  be  examined  by  sight  and 
touch  and  may  be  simple  or  compound,  and  (b)  those  of  the  base,  which 
have  to  be  diagnosed  by  other  signs  than  direct  examination  of  the  bones 
and  are  very  frequently  compound.  The  occurrence  of  fracture?  extending 
from  the  vault  to  the  base  is  not  uncommon  after  severe  injuries  to  the 
head. 

(a)  Fractures  of  the  Vault.  These  are  divided  into  (A)  simple 
(closed)  and  (B)  compound  (open),  according  as  the  scalp  is  intact  or  a 
wound  leads  down  to  the  site  of  fracture  ;  and  again  into  fissured,  where 
there  is  no  displacement  of  the  fragments,  and  depressed,  where  one  part 
of  the  skull  is  forced  below  the  normal  level. 

(A)  Simple  Fractures  of  the  Vault.  (1)  Simple  fissured  or  linear 
frat  tures  of  the  vault,  i.e.  without  breach  of  the  surface,  cannot  be  diagnosed 
with  certainty  from  contusions  of  the  skull,  but  may  cause  trouble  imme- 
diately from  some  intracranial  complication  or,  later,  from  pressure  of  callus 
on  the  brain. 

(2)  Simple  Depressed  Fractures  of  the  Vault.  These  are  caused  by  falls 
or  blows  on  the  vertex,  and  fall  into  two  groups,  according  to  the  manner 
of  indentation  of  the  skull. 

(a)  The  Pond  Depressed  Fracture.  In  these  cases  the  bone  slopes  dowTn 
gradually  to  the  bottom  of  the  depressed  area,  and  this  can  only  happen 
where  the  bone  is  soft,  the  fracture  being  of  the  "  green-stick  "  or  incomplete 
variety,  and  hence  it  is  rarely  found  except  in  infants  and  small  children. 

(b)  The  Gutter  Depressed  Fracture.  In  this  condition  one  part  at  least 
of  the  depression  is  abrupt,  so  that  a  sharp  edge  or  point  of  bone  projects 


SIMPLE  DEPRESSED  FRACTURES  OF  THE  CRAXIAL  VAULT     567 

into  the  interior  of  the  skull.  It  should  be  noted  that  the  shattering  of  the 
inner  table  of  the  skull  is  greater  than  the  depression  of  the  surface  would 
lead  one  to  suspect.  This  is  not  because  the  inner  table  is  more  fragile 
(from  which  erroneous  view  it  formerly  received  the  nanie'of  "  vitreous 
table  ")  but  because  in  break- 
ing down  an  arch  it  is  the 
lower,  unsupported  part  (in- 
ner table)  which  is  disrupted 
or  separated  and  tends  to 
fall  in  pieces  while  the  upper 
part  (outer  table),  being  com- 
pressed together  by  the 
crushing  force,  shows  less 
displacement. 

Signs.  There  may  or  may 
not  be  associated  concussion 
or  compression  of  the  brain. 
Locally  there  is  a  hsematonia 
over  the  fracture,  and  the 
surgeon  has  to  decide  whether 
the  bone  at  this  point  is  de- 
pressed by  trying  to  palpate 
the  bone  through  the  hema- 
toma, bearing  in  mind  where 
the  surface  of  the  skull  should 
be  if  intact.  Tracing  the  skull 
along  from  the  normal  part 
at  the  periphery,  diagnosis  is 
usually  easy  in  gutter  frac- 
tures, for  at  some  point  there 
is  a  sudden  dipping  in  of  the 
bone,  leaving  a  hard,  incom- 
pressible, sharp  edge,  with  a 

soft    vacancy     beyond.        In    Era.  231.     A,  linear  fracture  of  the  skull  with  slight 

-,    j.  ,,  .      hematoma  over  it  and  extradural  haemorrhage  beneath. 

pond    fracture  the    mattCr    IS    i:.    Fracture  of  the  inner   table,  the  outer  remaining 
less  easy  to  decide,  and  it  is  £**?*■       C,  depressed     (pond)     fracture    (greensticl 
,      ,    J  .  ,     .  .         ,.       fracture),    showing    no    sharp     edge.       D.    depressed 

only  by  Considering  that  the  (gutter)  fracture,  showing  the  Bharp  edge  on  one  side. 
curve  of  the  skull  will  bring   E'   Depressed  fracture  of  the  skull,  showing  p 

°  shattering  of  tin- jnii'T  tal.l.-. 

the  normal  level  of  the  lat- 

'ter,  in  the  centre  of  the  hsematonia,  to  a  higher  point  than  at  the  edpes 
that  one  can  avoid  making  mistakes.  As  mentioned  under  Hsematonia 
of  the  Scalp,  there  will  be  no  hesitation  in  exploring,  should  there  be 
any  doubt. 

Treatment.  Where  the  fracture  is  of  the  pond  variety  in  infants,  and 
if  there  are  no  signs  of  injury  to  the  brain,  such  as  paresis  of  limbs,  unequal 
pupils,  slow  pulse  or  respiration,  &c,  the  case  may  be  treated  simply  by 


- 


A  TEXTBOOK  OF  SIRCERY 


d  bed,  and  iii  most  instances  the  depression  will  disappear  in  a  few 
weeks.  In  all  cases  of  gutter  fractures  and  pond  fractures  in  other  than 
infants,  whether  there  are  signs  of  intracranial  complications  or  not.  or  in 
-  of  pond  fracture  in  infants  if  such  signs  be  present,  operation  should 
be  done  at  once,  the  skull  opened  with  trephine  or  otherwise,  and  loose 
fragments  removed  or  elevated,  a  search  being  made  in  the  periphery  Eor 
stray  portions  of  bone  pressing  on  the  brain.  This  operation  is  essential 
on  account  of  the  troubles  arising  later  (traumatic  epilepsy),  where  splin- 
tering of  the  inner  table  is  considerable  (which  cannot  be  negatived  without 
operative  inspection)  :  for  later  operations  in  cases  of  traumatic  epilepsy 
are  disappointing,  and  of  this  condition  it  may  be  said  with  much  emphasis 
that   "  prevention   is  better  than  cure."     In  skilled  hands  operating  on 


a-  — 


Fig.  232.  Diagram  of  diagnosis  of  hsematoma  and  scalp  and  depressed  fracture. 
A,  Haematoma  without  fracture;  the  point  a'  is  raised  above  the  line  c  c,  passing 
through  on  the  clotted  blood  at  the  edge  of  the  haeniatoma.  B.  Haematoma  with 
depressed  fracture  ;  the  point  h — the  depressed  portion — is  below  the  line  e'e',  which 
passes  through  b',  the  edge  of  the  fracture.  X,  Intradural  haemorrhage  and  lacerated 
brain.     Y.  Extradural  haemorrhage. 

depressed  fractures  is  very  safe,  and  almost  certainly  prevents  such  later 
complications  as  epilepsy. 

Traumatic  Cephal-hydrocccle.  This  is  an  uncommon  condition  following 
simple  fractures  of  the  vault  in  children.  There  is  a  pulsating  swelling  on 
the  scalp  containing  cerebro-spinal  fluid,  which  communicates  by  an  aperture 
in  the  skull  with  the  subdural  space  or  the  lateral  ventricle  or  with  a  cyst 
of  the  arachnoid.  The  pulsating,  translucent  swelling,  with  impulse  on 
coughing  and  history  of  previous  cranial  injury,  will  help  to  make  the 
diagnosis. 

Treatment.  The  cyst  is  explored,  the  aperture  in  the  dura  sutured,  any 
arachnoid  cyst  removed,  and  if  the  hole  in  the  skull  is  large  a  bone-graft 
placed  in  the  gap. 

(B)  Compound  Fractures  of  the  Vault.  These  result  from  falls  on 
the  head  or  the  impact  of  sharp,  blunt,  or  pointed  objects  or  weapons, 
including  bullets. 


COMPOUND  FRACTURES  OF  THE  CRANIAL  VAULT       569 

Various  types  of  fracture  are  found  :  (1)  linear  or  fissured  ;  (2)  depressed, 
which  are  often  comminuted  ;  (3)  punctured  (a  variety  of  depressed)  ; 
(4)  elevated  fractures  also  have  been  noted,  the  impact  of  a  sabre  or  axe 
partially  removing  a  portion  of  the  skull,  which  is  thus  elevated  from  the 
surrounding  surface.  In  some  instances  the  two  tables  are  fractured 
separately.  Thus  where  the  tables  are  widely  separated,  as  at  the  frontal 
sinus,  the  outer  table  alone  may  be  driven  inward  (simple  fractures  of  this 
kind  also  occur).  The  inner  table  is  sometimes  fractured  alone  by  the 
impact  of  a  glancing  bullet,  the  outer  table  bending  in  and  springing  out 
again  after  the  blow,  while  the  inner  table,  unsupported  on  its  inner  surface, 
gives  way  and  is  comminuted  (this  is  an  important  variety,  being  difficult 
to  diagnose  and  demanding  operative  treatment  with  opening  of  the  skull). 
(Fig.  231,  B.) 

As  in  simple  fractures,  the  inner  table  is  generally  more  splintered  than 
the  outer  owing  to  its  being  less  supported  ;  hence  where  a  bullet  traverses 
the  skull  at  the  wound  of  exit  the  outer  table  is  more  shattered  than  the 
inner. 

Signs.  In  addition  to  local  signs  there  may  be  varying  manifestations 
of  intracranial  injury,  from  the  mildest  concussion  to  gross  laceration  or 
compression  resulting  in  speedy  death. 

Locally,  if  the  dura  be  not  torn  the  condition  will  at  first  sight  resemble 
a  scalp-wound,  but  if  the  dura  is  torn  the  escape  of  clear  cerebro-spinal 
fluid  or  pulped  brain  may  render  the  condition  obvious  at  once.  On  a 
closer  examination  the  following  conditions  may  be  found. 

(1)  A  fissured  fracture  is  distinguished  as  a  blood-stained  line  in  the 
skull  in  a  place  where  no  suture  normally  exists  ;  this  line  may  feel  irregular 
to  the  finger  or  probe. 

(2)  Where  an  ordinary  depressed  fracture  is  present  the  sudden  loss  at 
one  point  of  the  normal  contour  of  the  skull  and  the  sharp  edge  to  the 
depression  are  unmistakable  if  the  wound  be  conscientiously  examined  with 
a  sterile  ringer. 

(3)  Punctured  fractures  are  easily  missed,  especially  if  made  with  a 
narrow  pointed  instrument  such  as  a  knife.  In  these  cases  the  depths  of 
the  wound,  enlarged  if  need  be,  should  not  only  be  explored  with  the  finger 
but  with  a  dissecting  tool,  which  will  penetrate  into  a  narrow  punctured 
fracture  better  than  a  probe.  Early  diagnosis  is  the  secret  of  success  in 
these  cases,  as  if  a  small  punctured  fracture  be  not  discovered,  till  infection 
has  advanced,  the  outlook  is  bad.  Hence  the  need  carefully  to  scrutinize 
small  wounds  of  the  scalp. 

Treatment.  (1)  Cases  of  linear  fracture  without  any  irregularity  of 
the  fragments  and  no  signs  of  cerebral  complication  may  be  treated  as 
scalp-wounds,  rendering  the  parts  aseptic  and  suturing,  but  watching  for  in- 
tracranial developments  and  trephining  if  these  arise  (which  is  not  common). 

Where,  however,  the  surface  of  such  fracture  is  starred  and  irregular. 
caused  by  impact  of  a  glancing  bullet,  or  if  any  hair  or  other  foreign  substance 
be  caught  in  the  line  of  fracture,  there  is  a  great  probability  that  the  inner 


A  TEXTBOOK  OF  SURGERY 

table  is  shattered  and  that  some  infection  may  have  been  introduced  into 
the  depths  of  the  fracture.  Therefore,  in  such  cases  the  skull  should  be 
opened,  loose  fragments  removed,  and  the  surface  of  the  dura  carefully 
cleaned  from  any  infective  substance. 

-  Where  the  fracture  is  depressed  and  comminuted  the  depressed 
fragments  must  -  moved  and  the  wound  carefully  cleaned  (trephining  if 
nee-    - 

Punctured  fractures,  however  small,  are  treated  by  opening  the 
skull,  on  account  of  the  danger  of  loose  fragments  penetrating  the 
brain  and  from  the  possibility  of  infection  being  introduced  into  the 
extradural  space  or  the  brain.  The  dangers  of  compound  depressed 
fractures  are  : 

Mechanical  injury  to  the  brain  from  penetration  of  the  latter  by 
fragments  or  acute  compression  by  depressed  fragments  or  haemorrhage, 
while  later  the  pressure  or  callus  and  scarring  may  cause  chromic  pressure 
on  the  cortex  and  set  up  Jacksonian  epilep- 

The  introduction  of  infective  material,  leading  to  osteomyelitis  of 
-.-aill  and,  what  is  far  more  important,  to  intracranial  infection,  which, 
though  readily  prevented  by  early  operation,  is  almost  impossible  to  cure 
when  fully  developed. 

ORATIONS  FOE  DEPRESSED  AND  PUNCTURED  FRACTURES.      The  patient 

being  anaesthetized  if  conscious,  the  scalp  is  shaved  and  rendered  aseptic. 
The  skull  is  exposed  either  by  enlarging  the  original  wound,  if  large,  or 
where  there  is  no  wound  or  a  small  punctured  wound  it  will  be  neater  to 
turn  down  a  flap  of  scalp,  bearing  in  mind  the  direction  of  the  main  vessels, 
and  suture  the  puncture,  having  cleaned  and  excised  its  edges. 

When  the  area  of  injury  is  fully  exposed  it  may  be  found  possible, 
where  there  is  much  comminution,  to  remove  loose  fragments  without 
trephining,  simply  enlarging  the  hole  as  necessary  with  rongeur  forceps. 
Where  the  fragments  are  not  loose  enough  to  admit  removal,  as  in  punc- 
tured fractures,  the  skull  will  require  opening  with  the  trephine,  the  centre- 
pin  of  which  is  placed  on  intact  skull  close  to  one  side  of  the  depression, 
the  margin  of  the  trephine  overlapping  the  depressed  area. 

The  trephine  is  rotated  in  alternate  directions  till  the  cutting  edge  has  a 
good  grip  on  the  outer  table.  The  pin  is  then  removed  and  the  rotations 
continued  :  increased  bleeding  shows  that  the  diploe  is  entered.  The 
of  the  trephine  should  be  brushed  clean  at  frequent  intervals  and  the 
wound  in  the  bone  irrigated  with  sterile  water  to  make  the  instrument  cut 
easily.  As  the  inner  table  is  approached  the  depth  of  the  cut  in  the  bone 
sted  with  a  dissecting  tool,  bearing  in  mind  that  the  thickness  of  the 
skull  is  very  different  in  parts  quite  close  together,  so  that  the  trephine 
may  be  quite  through  in  one  place  and  only  half  through  elsewhere.  Atten- 
tion to  these  details  will  help  to  avoid  injuring  the  dura.  When  the  circle 
of  bone  is  cut  almost  through,  it  can  be  easily  removed  with  the  elevator 
and  the  resulting  aperture  in  the  skull  enlarged  with  rongeur  forceps.  Long 
handles  are  advisable  for  these  instruments  unless  the  surgeon's  grasp  is 


OPERATIONS  FOB  DEPRESSED  FBA<  TUBES  OP  THE  VAULT    "" 

phenomenal.     Sometimes  I  _  .ay  be  elevated  into  position, 

but  most  will  be  removed  :  the  surface  of  the  dura  is  cleansed  with  dilute 
antiseptic  lotion  and  a  flat  prot.  md  the  margins  of  the 

depression  between  skull  and  dura  to  ensure  that  there  are  no  outlying 
depressed  fragments  impinging  on  the  dura.  Bleeding  from  the  cut  surface 
of  the  skull  is  readily  checked  by  rub  _  He  paraffin- wax  of  medium 
hardness    on    to    the    latter,   the    -  und   closed   with    interrupted 

sutures  and  drained  for  twenty-four  h»: 

There  is  no  need  to  replace  loose  fragments     :  ;  :he  resulting  - 

is  very  strong  and  resistant.  If  the  dura  is  found  injured  and  brain  be 
protruding    or   in  _ould  be  cleaned  with  lotion  or  excised   if 

pulped,  and  the  dura  sutured  in  place. 

In  all  cases  where  there  are  signs  of  cerebral  complications  (unless  these 
can  be  accounted  for  bv  the  amount  of  c.  I  :le  the  dura)  the  latter 

should  be  opened  and  the  brain  explored,  as  subdural  haemorrhage  may  be 
causing  severe  pressure  symptoms.  The  treatment  of  gunshot  wounds 
of  the  skull  is  similar  to  that  f  ired  fractures  as  far  as  the  skull  is 

concerned  where  the  brait.  :rated  will  be  discussed  under 

Injuries  of  the  Brain.  After  dealing  with  fractures  of  the  skull  the  patient 
should  be  kept  quiet  in  bed  with  the  head  raised  and  the  bowels  freely 
opened  for  at  rteen  days,  and  a  careful  watch  be  kept  for  signs  of 

intracranial  mischief.     The  pal  old  do  no  hard  work  for  two  to 

three  months,  and  if  there  have  been  any  _\  -  of  injury  to  the  brain  for 
a  considerably  longer  period. 

(6)  Fractuees  of  the  Base  of  the  Skull.  These  are  usually  fissured, 
sometimes  punctured  or  cl  and  very  often  compound-    There  are 

several  ways  mechanically,  in  which  these  fractures  occur. 

(1)  Irradiation  (Aran).     As  the  result  of  a  fall  or  blow  on  the  ve 

the  latter  may  be  fractured,  and  if  the  violence  be  great  the  fracture  may 
spread  or  radiate  to  the  h   - 

(2)  Com  press  ion.  When  the  skull  is  compressed  by  falls,  blows,  or 
actual  crushing  it  tends  to  burst  in  lines  parallel  to  the  compressing  force, 
rarelv  at  right  angles  to  this  is  in  a  fall  on  the  vertex,  the  skull  being 
compressed  between  the  vertex  and  the  foramen  magnum,  where  the  verte- 
bra? are  driven  against  the  base,  the  line  of  fracture  will  radiate  from  the 
foramen  either  in  a  sagitt  or  a  coronal  direction.  If  the  skull  be  crushed 
under  a  cart-wheel  while  on  r-  ■  the  line  of  fracture  will  run  across 
the  base  in  a  coronal  or  tran-       -  I    n. 

(3)  Direct  violence  accounts  for  a  number  of  usually  depressed 
or  punctured,  such  as  thoa  to  pointed  objects  thrust  through  the 
roof  of  the  orbit,  nasal  fossa,  or  the  naso-pharynx  :  bullet  wounds  through 
the  roof  of  the  mouth  in  or  bayonet  wounds,  which  may 
penetrate  the  posterior  fossa  in  the  occipital  region. 

(4)  Fractures  definitely  due  to  indirect  violence  may  result  from  falls 
from  a  height  on  the  ebral  column  being  driven 
forciblv  against  the  base  of  the  skull,  which  gives  way  ;  or  a  blow  upwards 


■».L' 


A    I KXTBOOK  OF  SURGERY 


on  the  jaw  may  drive  the  condyle  of  the  latter  so  hard  against  the  glenoid 

fossa  as  to  cause  fracture. 

Fractures  in  this  situation  may  run  in  any  direction  and  may  be  confined 

to  one  of  the  fossa'  of  the  base,  especially  d'  transverse  in  direction,  but  if 

longitudinal    may    traverse    all   three  fossa?.      Fractures    of   the    anterior 

and  middle  fossae  are   usually  compound.      In  the  case  of  the  anterior 

lossa  the  opening  will  be  into 
the  nasal  cavity  through  the 
cribriform  plate  or  through  a 
punctured  wound  piercing  the 
roof  of  the  orbit  (many  cases  of 
fractures  in  this  fossa  being  of 
the  punctured  variety).  In  the 
middle  fossa  the  fracture  may 
open  into  the  naso-pharynx, 
but  more  often  communicates 
with  the  outside  via  the  external 
ear  through  a  rupture  of  the 
tympanic  membrane  and  fracture 
of  the  petrous  bone.  Fractures 
of  the  posterior  fossa  are  more 
often  simple,  but  may  be  com- 
pound into  the  pharynx  through 
the  basi-occipital  or  from  a 
punctured  wound  in  the  occi- 
pital region  to  which  they  owe 
their  causation.  The  import- 
ance of  fractures    of  the  base 

of  the  skull  is  due  to  the  complications  associated  with  or  arising  from 

them,  viz.  : 

(1)  Infection  of  the  brain  or  meninges  owing  to  their  usually  compound 
nature. 

(2)  Laceration  of  the  brain. 

(3)  Laceration  of  the  large  blood-sinuses  or  meningeal  arteries,  leading 
to  haemorrhage  and  compression  of  the  brain. 

(4)  Injuries  to  nerves,  particularly  to  the  auditory  and  facial  nerves  in 
fractures  of  the  middle  fossa  ;  less  often  injury  of  the  optic,  olfactory,  and 
Oculomotor  nerves  in  fractures  of  the  anterior  fossa. 

Cigns  and  Diagnosis.  These  fractures  are  seldom  diagnosed  from  direct 
observation  of  the  fracture  by  sight  or  touch.  Still,  in  punctured  or  gun- 
shot wounds  of  the  orbit  and  upper  pharynx  and  occiput  it  may  be  possible 
to  detect  the  fracture  with  finger  or  probe,  and,  especially  in  the  case  of 
punctured  wounds  about  the  orbit,  it  behoves  the  surgeon  to  use  the  greatest 
care  to  exclude  such  dangerous  conditions.  In  most  cases  there  are  marked 
of  cerebral  injury,  such  as  concussion  with  prolonged  unconsciousness, 
cerebral  irritation,  or  compression  ;    but  these  signs  may  be  absent,  and  if 


Fig.  233.     Possible  directions  of  fracture 
of  the  base  of  the  skull. 


SIGNS  OF  FRACTURE  OF  THE  BASE  OF  THE  SKULL     573 

present  are  by  no  means  conclusive  evidence  of  fracture  of  the  base  of  the 
skull,  though  if  combined  with  other  signs  (also  not  infallible)  such  as 
bleeding  from  the  ear,  injury  to  cranial  nerves,  &c,  are  strong  presumptive 
evidence  that  the  basis  cranii  has  been  shattered. 

The  only  proof  positive  of  such  fractures  (apart  from  seeing  or  feeling 
the  rough  edges  of  the  bone)  consists  in  noting  the  escape  of  brain  or 
cerebro-spinal  fluid  from  the  nose,  mouth,  ear,  or  from  some  punctured 
wound. 

Brain  is  recognized  by  its  whitish  colour  and  pulpy  texture. 

Cerebro-spinal  fluid  is  a  perfectly  clear  fluid,  usually  escaping  in  large 
quantities,  having  a  low  specific  gravity  (1003),  which  does  not  clot  on 
standing  or  coagulate  on  boiling  (distinguishing  it  from  lymph  and  serum), 
and  on  boiling  with  Fehling's  solution  reduces  the  copper  owing  to  the 
presence  of  pyrocatechin. 

Escape  of  blood  is  an  equivocal  sign,  but  under  certain  conditions  is 
good  evidence  of  fractured  base.  (1)  When  the  anterior  fossa  is  fractured 
the  blood  may  escape  from  the  nose,  but  there  are  so  many  causes  of  trau- 
matic epistaxis  dear  to  English  youth  that  bleeding  from  this  orifice  is  of 
little  moment.  Blood  escaping  from  the  nasal  fossse  and  pharvnx  may 
be  swallowed  and  again  vomited,  which  is  a  point  to  remember  in  considering 
the  question  as  to  whether  the  injury  of  the  skull  is  complicated  by  one  of 
the  abdomen.  Far  more  important  is  an  effusion  of  blood  into  the  ocular 
conjunctiva.  This  is  to  be  distinguished  from  the  common  ecchymosis  of 
the  orbital  conjunctiva  (black-eve)  by  its  not  arising  for  some  hours  after 
the  injury  (a  black-eye  is  well  developed  in  a  few  minutes)  and  in  not  affect- 
ing the  orbital  conjunctiva.  The  characteristic  picture  of  orbital  ecchymosis 
from  fracture  of  the  anterior  fossa  is  a  black  patch  on  the  outer  side  of  the 
eyeball  triangular  in  shape,  with  its  apex  pointing  to  and  not  far  from 
the  cornea.  Where  the  bleeding  into  the  orbit  is  gross  there  may  be  prop- 
tosis.  Sometimes  in  fractures  of  the  anterior  fossa  there  is  a  large  effusion 
of  blood  above  the  front  of  the  zygoma  (especially  if  the  middle  meningeal 
artery  is  torn).  (2)  In  fractures  of  the  middle  fossa  blood  may  escape 
from  the  mouth  or  nose,  but  this  bleeding,  as  mentioned  above,  is  but 
slender  evidence  in  favour  of  fracture.  When  escaping  from  the  ear  in 
some  quantity  it  is  likely  that  the  base  of  the  skull  is  fractured  ;  but  bleeding 
here  may  be  due  to  laceration  of  the  external  auditory  meatus  or  simple 
laceration  of  the  membiana  tympani,  though  in  the  latter  case  the  bleeding 
will  not  be  extensive.  (3)  l)\  fractures  of  the  posterior  fossa  there  may 
be  ecchymosis  about  the  occiput  and  mastoid. 

Injuries  to  nerves  are  especially  found  when  the  middle  fossa  is  frac- 
tured through  the  petrous  bone  the  facial  and  auditory  nerves  being  torn, 
leading  to  internal  ear  deafness  and  facial  paralysis  of  tin1  lower-segment 
type,  with  wasting  and  reaction  of  degeneration  of  the  muscles. 

Prognosis.  This  chiefly  depends  on  the  associated  cerebral  Lesion,  as 
with  modern  aseptic  precautions  infection  of  the  brain  and  meninges  can 
be  often  avoided,  and  thus  ;'  considerable  number  of  cases  recover. 


574  A    TEXTBOOK  OF  SURGERY 

Treatment.  The  first  indication  is  to  prevent  infection  through  the 
shattered  bone  where  the  fracture  is  compound.  The  opening  is  usually 
in  the  ear  or  nose  ;  in  the  former  instance  the  external  meatus  is  gently 
syringed  with  1  in  20  carbolic  and  packed  with  a  strip  of  sterile  cyanide 
gauze,  replaced  as  often  as  it  becomes  soaked  with  blood.  Where  the  fracture 
is  into  the  nasal  fossae  it  is  unwise  to  plug  these,  as  the  upper  nasal  passages 
are  apt  to  be  sterile  and  plugging  here  is  likely  to  introduce  sepsis  rather 
than  to  prevent  it.  Urotropin  should  be  administered  to  all  these  cases 
(advocated  by  dishing  for  intracranial  operations  done  via  the  nasal  fossae), 
as  it  is  excreted  in  the  cerebro-spinal  fluid  and  renders  infection  of  this 
less  easy.  As  fractures  of  the  base  in  the  anterior  fossa  are  often  through 
the  roof  of  the  orbit,  it  follows  that  these  will  often  be  compound  punctured 
fractures  caused  by  such  objects  as  sticks  or  umbrellas.  Care  is  needed 
not  to  miss  such  injuries  in  exploring  a  wound  of  the  orbit,  and  the  surgeon 
should  not  be  satisfied  in  these  cases  till  he  is  sure,  after  examination  with 
finger  and  probe,  that  the  roof  of  the  orbit  is  intact.  Where  a  punctured 
fracture  of  the  orbital  roof  is  discovered,  this  is  explored  through  an  incision 
below  the  eyebrow,  the  eyeball  being  gently  depressed,  the  opening  in  the 
floor  of  the  anterior  fossa  enlarged,  loose  fragments  or  foreign  bodies  removed, 
and  the  cavity  sterilized  as  far  as  possible  and  closed  with  drainage  for 
twenty-four  hours. 

Having  made  all  arrangements  to  maintain  asepsis,  the  patient  is  placed 
in  bed  with  the  head  raised  to  lower  the  intracerebral  pressure  and  diminish 
effusion  of  blood  inside  the  cranium.  The  benefit  of  an  ice-bag  applied 
to  the  shaved  head  is  problematical,  as  in  practice  it  seldom  remains  applied 
to  the  head  for  long  together.  Diet  should  be  light  and  the  bowTels  should  be 
kept  freely  open  with  calomel  and  the  patient  watched  for  development  of 
intracranial  complications. 

Meningitis,  shown  by  high  fever,  rigors,  rapid  pulse,  rigidity  of  neck 
and  back,  is  a  hopeless  condition,  but  signs  of  compression  from  haemorrhage 
inside  the  skull  should  be  carefully  noted.  These  are  deepening  uncon- 
sciousness passing  into  coma,  slow  full  pulse,  slow  respiration,  paralysis  of 
limbs,  and  optic  neuritis  {see  Compression  of  the  Brain).  In  these  cases 
operative  measures  are  essential.  The  temporal  muscle  should  be  split 
along  its  fibres  and  a  large  ( ircle  of  bone  about  three  inches  in  diameter 
removed  in  the  subtemporal  region  to  alleviate  the  effects  of  compression  : 
good  results  are  reported  ((  ashing),  and  no  case  of  fracture  of  the  base  should 
be  allowed  to  die  from  cerebral  compression  without  making  some  attempt 
to  relieve  the  condition  by  operative  measures.  In  less  severe  cases  where 
operation  is  not  needed,  the  patient  should  remain  in  bed  till  at  least  four- 
teen days  after  consciousness  has  returned  and  may  be  allowed  up  when 
there  is  no  longer  headache  or  giddiness,  but  should  not  go  back  to  work 
tor  at  least  three  months. 

I  n  f  E(  "i  cons  and  I  x  i '  la  mmations  of  the  Cranium  Acute  infections  are 
due  to  the  pyogenic  organisms  (usually  staphylococci) ;  the  chronic  varieties 
arise  from  syphilis,  tubercle,  and  injuries. 


PYOGENIC  INFECTIONS  OF  THE  CRANIUM  575 

(a)  Acute  Infections.  Infections  of  the  bones  of  the  cranium  may  result 
from  infection  of  scalp,  wounds  of  the  skull  such  as  depressed  fractures, 
infection  from  the  neighbouring  air  sinuses  such  as  the  mastoid,  less  often 
the  frontal  sinus,  or  from  blood-borne  infection  of  subpericranial  haematomas. 

The  infection  may  involve  the  outer  table  only,  with  effusion  of  pus 
under  the  pericranium  and  necrosis  of  the  outer  table  (pericranial  abscess), 
or  may  involve  the  whole  thickness  of  the  skull,  causing  osteomyelitis  or 
necrosis  of  the  latter  and  leading  to  formation  of  pus  under  the  bone  (sub- 
cranial or  extradural  abscess).  Owing  to  the  free  openings  of  the  diploic 
veins,  when  these  thrombose  in  the  course  of  inflammation,  there  is  great 
risk  of  detachment  of  clots  leading  to  pyaemia  and  septicaemia. 

Signs.  The  seat  of  origin  is  commonly  an  infected  wound,  which  becomes 
swollen,  red,  boggy  and  oedematous,  the  edges  unhealthy  with  thin  sanious 
discharge  ;  irregular  pyrexia  and  headache  are  noted.  This  condition  is 
known  as  "  Pott's  puffy  tumour,"  and  generally  implies  necrosis  of  the  whole 
thickness  of  the  bone  with  a  subcranial  abscess.  The  oedematous  swelling 
behind  the  ear  in  acute  suppuration  of  the  mastoid  is  very  similar  to  the 
puffy  tumour  but  is  less  often  associated  with  intracranial  suppuration, 
perhaps  owing  to  the  greater  thickness  of  the  bone  at  this  point  (this  form 
of  osteitis  of  the  skull  is  described  under  Diseases  of  the  Ear,  p.  615). 

As  the  infection  advances,  intermittent  fever,  sweats,  diarrhoea,  and 
patchy  pneumonia  point  to  the  advent  of  general  infection  and  to  an  almost 
hopeless  prognosis. 

Treatment.  This  must  be  early  and  decided  :  the  infected  area  is 
freely  opened  up  ;  infected  bone,  which  is  known  by  its  white  dry  surface 
or  thrombosed  vessels  and  pus  in  the  diploe,  is  all  cut  away  till  healthy 
bleeding  bone  is  exposed  all  round  (the  original  aperture  is  made  in  most 
cases  with  a  trephine).  When  there  is  any  doubt  as  to  the  presence  of  pus 
inside  the  cranium  there  should  be  no  hesitation  in  removing  the  whole 
thickness  of  skull  and  exposing  the  dura,  for  as  long  as  the  surgeon  keeps  to 
the  outside  of  the  dura  there  is  no  risk  of  infecting  the  meninges,  while  if 
left  alone  a  subcranial  abscess  will  shortly  cause  infection  to  spread  to  the 
inside  of  the  dura  and  set  up  lepto-meningitis,  cerebral  abscess,  or  diffuse 
meningo-encephalitis.  After  removing  all  diseased  bone  and  the  under- 
lying pus,  the  cavity  is  irrigated  with  peroxide  and  lightly  packed  with 
gauze,  being  irrigated  daily  with  peroxide  of  hydrogen.  A  careful  watch  is 
kept  for  evidence  of  metastatic  infection  in  joints,  pleura,  pericardium,  or 
under  the  skin,  and  the  resulting  abcesses  opened  as  they  develop. 

(b)  Chronic  Inflammations  of  the  Cranium.  (1)  Traumatic  hyperostosis 
of  the  skull  may  be  the  result  of  a  blow,  an  osseous  node  forming  on 
the  surface  of  the  skull,  probably  as  the  result  of  ossification  in  a  sub- 
periosteal haematoma.  Intermittent  injuries  such  as  arise  from  carrying 
weights  on  the  head  may  also  lead  to  chronic  inflammation  and  thickening 
of  bone. 

Treatment.  If  causing  trouble  the  occupation  should  be  changed,  a 
suitable  pad  worn,  or  the  hypertrophic  bone  removed  with  the  chisel. 


A  TKXTBOOK  OF  SURGERY 

2)  Syphilitic  affections  of  the  skull  occur  in  the  secondary  and  tertiary 
stages  <>f  the  disease  as  well  as  in  the  congenital  form,  in  which,  as  Parrot's 
nodes  about  the  anterior  fontanelle,  they  have  already  been  mentioned  in 
ction  on  Diseases  of  Bone. 

(a)  Secondary  Byphilis  of  the  skull  occurs  in  the  form  of  nodes,  found, 
in  the  later  secondary  or  early  tertiary  stage,  situated  on  the  frontal  and 
parietal  regions.  The  nodes  consist  of  newly  formed  spongy  subperiosteal 
hone,  which  subsequently  scleroses. 

Diagnosis.  The  patient  complains  of  headaches,  and  as  the  pain  radiates 
and  the  nodes  are  not  much  raised  he  may  fail  to  notice  the  swelling.  Hence 
the  importance  of  palpation  of  the  skull  in  all  cases  of  headache  of  obscure 
origin.  Like  other  chronic  inflammations  of  bone,  the  pain  is  more  notice- 
able at  night.  The  feeling  of  one  or  more  slightly  raised  and  tender  nodes 
is  characteristic. 

Treatment.  The  pain  is  relieved  almost  at  once  by  iodides,  but  of  course 
at  this  early  stage  a  full  course  of  antisyphilitic  treatment  should  be 
employed. 

(6)  In  tertiary  syphilis  gummata  are  found  in  the  skull,  affecting  usually 
the  outer  table,  which  necroses  and  separates  very  slowly.  Where  a  number 
of  gummata  occur  together  a  large  area  of  the  outer  table  will  separate, 
the  gummata  bursting  on  the  surface  and  being  found  as  typical  tertiary 
ulcers  with  serpiginous  outline,  the  floor  of  which  is  bare,  worm-eaten  bone. 
As  the  separation  of  sequestra  is  very  slow  there  is  always  a  risk  of  a  secon- 
dary pyogenic  infection  leading  to  thrombosis  of  the  diploic  vessels  and 
meningitis,  pyaemia,  &c. 

Diagnosis.  This  rests  on  the  appearance  of  the  gumma  or  ulcer,  the 
past  history  of  syphilis,  and  the  serum  reaction. 

Treatment.  In  the  early  stages  before  the  gummata  have  burst,  mercury 
and  iodides  in  full  doses  will  promote  absorption  and  salvarsan  should  be 
given.  Later,  when  there  are  large  bare  sequestra  to  separate,  it  will  be 
better,  in  view  of  the  possibilities  if  secondary  infection  arises,  to  remove 
all  sequestra  with  chisel  till  healthy  bone  is  reached,  and  when  granulation 
of  the  surface  of  the  bone  is  established  to  cover  in  defects  with  Thiersch 
skin-grafts — the  specific  treatment,  of  course,  being  continued. 

(3)  Tuberculous  Injection  of  the  Cranium.  This  is  uncommon  except  when 
spreading  from  the  mastoid  in  infants,  but  may  arise  secondary  to  lupus  of  the 
scalp  or  in  patients  debilitated  from  advanced  disease  of  joints  and  glands. 

Commencing  as  a  pericranial  node,  this  breaks  down  into  caseous  material 
and  the  process  spreads  through  the  bone.  The  youth  of  the  patient  as 
well  as  the  cheesy,  carious  nature  of  the  process  and  the  weak,  anaemic 
granulations  readily  distinguish  the  condition  from  the  florid  necrosis  of 
syphilis,  when  the  cold  abscess  has  burst  on  the  exterior.  The  outlook  is 
bad  in  most  instances,  as  infection  is  likely  to  spread  to  the  meninges  or 
sinuses,  and  so  to  the  lungs  and  brain. 

'/'/"ifment.  Removal  of  all  infected  bone,  which  is  likely  to  be  far  more 
extensive  than  appears  on  the  surface. 


TUMOURS  OF  THE  CRANIUM  577 

(4-)  Rickets  affecting  the  skull  is  mentioned  in  the  section  on  General 
Disease  of  Bone. 

Tumours  of  the  Cranium.  Of  primary  tumours  we  find  osteomas  and 
sarcomas,  the  latter  often  being  ossified  ;  secondary  new  growths  are  usually 
carcinomas. 

(a)  Osteomas  are  of  the  dense  ivory  type,  and  usually  grow  in  the 
orbital  plate  of  the  frontal  bone  or  from  the  interior  of  the  external 
auditory  meatus. 

These  tumours  are  painless,  hard,  sessile  formations  of  very  slow 
growth,  rising  sharply  from  the  surrounding  bone  and  are  of  little 
consequence  except  from  their  position.  Thus  growths  of  the  orbital 
plate  will  ultimately  cause  pressure  on  the  brain,  while  those  of  the 
auditory  meatus  interfere  with  hearing,  or  if  otitis  media  be  present, 
obstruct  free  discharge  and  may  lead  to  intracranial  complications. 

Treatment.  In  the  auditary  meatus  they  should  be  removed  with 
chisel  or  dental  engine,  care  being  taken  of  the  membrana  tympani. 

Larger  growths  of  the  frontal  bone  should  be  removed  with  trephine, 
saw  or  engine,  owing  to  the  concussion  caused  by  the  mallet  and  chisel  on 
such  dense  bone,  and  the  operation  may  prove  very  extensive. 

(b)  Sarcomas  of  round-  or  spindle-celled  types  may  originate  in  the 
pericranium  or  spread  through  from  the  dura.  Periosteal  sarcomas  grow 
rapidly,  and  may  be  soft  and  pulsating  or  hard  if  there  is  much  formation 
of  new  bone. 

Myeloid  sarcomas  occasionally  arise  in  the  cancellous  diploe  and  grow 
slowly,  expanding  the  bone,  which  becomes  thinned  and  gives  the  sensation 
of  "  horn-lanthorn  bending  "  or  "  egg-shell  crackling."  Either  variety  may 
fungate  through  the  skin. 

Diagnosis.  A  radiograph,  as  well  as  the  different  rate  of  growth,  will 
distinguish  between  endosteal  and  periosteal  sarcomas.  When  the  tumour 
is  spreading  from  the  dura  there  will  be  a  preceding  history  of  headache 
and  vomiting,  while  optic  neuritis  will  be  noted  in  many  instances. 

(c)  Secondary  malignant  deposits  in  the  cranium  are  cancerous  and 
present  similar  signs  to  sarcomas,  pulsation  being  common.  They  are  most 
often  secondary  to  cancer  of  the  thyroid. 

General  Diagnosis  of  Cranial  Swellings.  Inflammatory  lumps  are  painful 
and  tender,  rising  gradually  from  the  normal  bone,  and  often  break  down 
rapidly  into  abscesses  or  gummatous  ulcers.  New  growths  are  painless 
and  not  tender  at  first,  rapidly  growing  if  malignant,  slow-growing  if  inno- 
cent, and  in  either  case  rise  sharply  from  the  surrounding  bone.  Radio- 
graphs will  show  dense  bone  in  the  case  of  exostoses,  radiating  formation  of 
newbone  in  periosteal  sarcoma,  and  expansion  of  the  bone  if  myeloid.  As 
the  signs  of  secondary  growth  are  similar  to  those  of  primary  growth,  it  is 
necessary  to  exclude  by  examination  all  possible  sources  of  primary  growth 
such  as  the  breast,  or  above  all  the  thyroid. 

Treatment  of  Malignant  Growths.  Thorough  removal  with  the  under- 
lying skull  gives  the  only  hope  of  success  in  the  case  of  periosteal  sarcomas  ; 

i  37 


578  A  TEXTBOOK  OF  slIJCKKV 

the  use  in  addition  of  (nicy's  fluid  and  X-rays  may  render  recurrence  less 
likely,  hut  the  prognosis  is  not  good. 

Myeloid  growths  may  he  cured  by  local  removal,  chiselling  and  curetting 
away  the  mass,  but  it  will  be  safer  to  remove  the  whole  thickness  of  skull. 

Secondary  growths,  or  those  spreading  from  the  dura,  are  in  most  cases 
best  let  alone. 

AFFECTIONS  OF  THE  BRAIN 

Anatomy  and  Physiology.  The  brain  being  enclosed  in  an  inelastic 
covering,  the  dura,  and  in  a  still  more  rigid  case  the  skull,  is  unable  to  expand 
as  a  whole,  and  it  follows  that  enlargement  of  any  one  part  can  only  take 
place  at  the  expense  of  some  other  part  or  parts.  From  a  hydrostatic 
standpoint  the  cranial  contents  consist  of  the  brain  substance  proper  floating 
in  a  collection  of  fluid,  which  consists  of  the  blood  contained  in  the  arteries, 
capillaries,  veins  and  sinuses,  and  the  cerebro-spinal  fluid,  which  is  a  secre- 
tion from  the  blood  through  the  choroid  plexuses  and  occupies  the  ventricles 
of  the  brain  and  subarachnoid  space,  these  spaces  being  in  communication 
with  each  other  through  the  foramen  of  Majendie  in  the  roof  of  the  fourth 
ventricle.  There  is  no  vasomotor  supply  to  the  vessels  of  the  brain,  and 
hence  changes  in  its  arterial  supply  are  effected  by  changes  in  the  vaso- 
motor system  of  the  body  generally.  Thus,  if  pressure  be  slowly  exerted 
on  the  brain  the  amount  of  cerebro-spinal  fluid  is  lessened  inside  the  cranium 
by  escape  into  the  spinal  canal  and  venous  sinuses.  If,  however,  the 
pressure  is  increased  rapidly,  as  by  a  depressed  fracture  or  intracranial 
haemorrhage,  the  cerebro-spinal  fluid  cannot  escape  fast  enough  and  the 
smaller  arterioles  and  capillaries  are  compressed,  diminishing  the  blood- 
supply  to  the  brain  locally  or  generally.  The  attempt  to  force  blood  through 
the  diminished  channel  causes  a  general  rise  of  blood-pressure,  and  thus 
the  small  vessels  are  exposed  to  the  full  strength  of  the  arterial  pressure, 
which  may  burst  them.  The  effect  of  a  general  rise  in  the  intracranial 
pressure  is  to  force  the  cerebral  hemispheres  back  on  the  pons  and  medulla, 
producing  interference  with  their  blood-supply  and  so  affecting  the  impor- 
tant respiratory  and  vasomotor  centres  lying  there.  Restoration  of  equili- 
brium is  attained  by  escape  of  cerebro-spinal  fluid  through  the  foramen 
magnum,  along  nerve-sheaths  and  by  drainage  into  venous  channels,  or  by 
surgical  opening  of  the  cranium,  which  alters  the  hydrostatic  conditions  of 
the  cranial  circulation  by  converting  it  from  a  closed  into  an  open  box. 
Even  a  small  escape  of  cerebro-spinal  fluid  will  allow  the  veins  to  become 
unobstructed  and  restore  the  circulation.  The  rise  of  general  blood- 
pressure  needed  to  force  the  blood  through  the  greater  resistance  falls 
when  "  decompression  "  (making  a  wide  opening  in  the  skull)  has  been 
effected.  Thus  it  would  appear  that  the  main  effect  of  raising  the 
intracranial  pressure  is  to  produce  anaemia  of  the  brain,  both  local  and 
general . 

The  inner  surface  of  the  dura  resembles  a  serous  membrane,  but  compared 
wdth  the  peritoneum  has  but  slight  power  of  forming  protective  adhesions, 


CEREBRAL  PHYSIOLOGY  AND  TOPOGRAPHY  579 

and  thus  infection  readily  spreads  underneath  it,  over  and  amongst  the 
arachnoid  and  pia  mater,  causing  diffuse  leptomeningitis. 

The  falx  cerebri,  a  projection  of  the  dura  in  the  sagittal  direction,  lies 
between  the  two  hemispheres  of  the  cerebrum,  and  at  its  attachment  along 
the  roof  of  the  cranium  is  the  large  superior  longitudinal  sinus.  The 
tentorium,  another  projection  of  the  dura  in  a  nearly  horizontal  direction 
from  the  inner  surface  of  the  occipital  and  the  upper  inner  edges  of  the 
petrous  bones,  separates  the  cerebrum  from  the  cerebellum,  and  in  its 
posterior  part  contains  between  its  folds  the  sigmoid  or  lateral  sinus, 
into  which  the  longitudinal  sinus  bifurcates  posteriorly.  The  meningeal 
vessels,  of  which  the  middle  is  of  surgical  importance,  lie  in  the  dura 
mater. 

The  immediate  covering  of  the  brain  is  the  fine  pia  mater,  projections 
of  which  dip  into  the  substance  of  the  brain  and  carry- vessels  derived  from 
the  carotid  and  vertebrate  v  a  the  circle  of  Willis  at  the  base.  The  pia 
mater  is  firmly  adherent  to  the  brain.  Between  the  dura  and  the  pia 
mater  is  the  meshwork  of  arachnoid  containing  the  arachnoid  space,  which 
is  expanded  in  places  into  large  spaces  or  "  cisterns,"  particularly  below 
the  mid-brain  in  front  of  the  pons,  and  between  the  cerebellum  and  medulla, 
into  the  latter  of  which  the  fourth  ventricle  opens  by  an  aperture  in  its 
roof,  the  foramen  of  Majendie. 

The  functions  of  various  portions  of  the  brain,  notably  those  of  the 
cortex,  have  been  to  some  degree  worked  out  by  studies  in  animals,  by 
post-mortem  work,  and  operations  in  cases  of  cerebral  disease,  and  various 
systems  of  cerebro-cranial  topography  have  been  devised  to  find  these 
areas  with  certainty  from  the  surface  of  the  skull. 

<  i:rebro-cranial  Topography.  This  includes  the  surface  markings  of 
the  vessels  and  areas  of  the  cerebral  cortex,  both  motor  and  sensory. 

The  following  points  are  important  in  marking  out  the  contents  of  the 
cranium  : 

The  nation  or  fronto-nasal  suture ;  the  inion  or  external  occipital 
protuberance  ;  the  externa!  angulai  process  of  the  frontal  bone  at  the  upper 
and  outer  margin  of  the  orbit ;  the  preauricular  point,  a  swelling  on  the 
root  of  the  zygoma  in  front  of  the  external  auditory  meatus  and  at  the  base 
of  the  tragus  (this  is  the  point  of  crossing  of  the  superficial  temporal  vessels 
and  auriculo-temporal  nerve).  The  bregma,  or  vertical  point,  is  at  the 
junction  of  the  coronal  and  sagittal  sutures,  and  is  vertically  above  the  prae- 
auricular  point  and  two  inches  in  front  of  the  upper  end  of  the  fissure  of 
Rolando.  The  lambda,  or  junction  of  the  sagittal  and  lambdoid  sutures, 
corresponds  to  the  posterior  end  of  the  Sylvian  line.  The  ptt  rion  or  junction 
of  the  frontal,  parietal,  and  sphenoid  bones  is  nearly  at  the  Sylvian  point 
or  origin  <>1  the  Sylvian  fissure  (see  later). 

The  following  lines  are  of  value  : 

(1)  Reid's  base  line,  which  runs  through  the  lower  margin  of  the  orbit 
and  the  centre  of  the  external  auditory  meatus  ;  this  is  horizontal  when  the 
skull  is  in  the  normal  position. 


580 


A  TEXTBOOK  OF  SURGERY 


(•_')  The  middle  meningeal  line  (Chiene)  is  made  by  taking  the  mid-point 
ot  tin1  line  joining  the  preauricular  poinl  and  the  external  angular  process 
and  drawing  a  line  from  this  point  to  the  point  half -way  between  the  oasiorj 
and  the  inion.  Tins  meningeal  line  gives  the  direction  of  the  trunk  and 
anterior  branch  of  the  middle  meningeal  artery  and  lies  half  an  inch  in  limit 
of  the  Rolandic  fissure.     The  posterior  branch  of  the  meningeal  artery  runs 

TV 


VISUAL 


Fig.  234.  Cerebro-cranial  topography,  after  Chiene's  method.  I,  Inion.  N. 
Nasion.  M.  Middle  meningeal  point  =  \  I,  N.  m,  Mid- point  between  the  external 
angular  process  E  and  preauricular  point  X.  Mm  is  the  anterior  branch  of  the  middle 
meningeal  artery.  K,  The  Rolandic  point.  S,  =11,  M,  is  the  Sylvian  point. 
S,  E.  Sylvian  line.  0  =  \  S,  I.  A  is  the  "Asterion'  mid-point  between  ()  and  the 
preauricular  point.  P  is  the  Pterion  at  the  junction  of  the  limbs  of  the  Sylvian 
1 1— ure.     Reid's  horizontal  base  line  through  1  and  the  lower  margin  of  the  orbit  is 

shown. 

back  parallel  with  Reid's  line  (horizontally)  from  the  mid-point  between  the 
external  angular  process  and  the  preauricular  point. 

(3)  The  Sylvian  line  (Chiene)  is  made  by  joining  the  external  angular 
process  and  a  point  three- quarters  of  the  distance  back  from  the  nasion  to 
the  inion.  This  line  cuts  the  middle  meningeal  line  just  behind  the  pterion. 
The  balf-inch  of  the  Sylvian  line  in  front  of  the  meningeal  line  represents 
the  anterior  limb  of  the  Sylvian  fissure  ;  the  three  inches  posterior  to  the 
meningeal  line  represent  the  main  Sylvian  fissure. 

(4)  The  line  joining  the  preauricular  point  with  a  point  seven-eighths 
of  the  way  back  along  the  naso-inial  line  crosses  at  half-way  the  point  where 


CORTICAL  AREAS  581 

the  lateral  sinus  alters  its  course  from  the  horizontal  posterior  to  the  oblique 
anterior  part  which  grooves  the  deep  surface  of  the  squamous  and  mastoid 
bones,  and  this  point  or  junction  of  the  occipital,  parietal,  and  mastoid 
bones  is  the  a -iter  ion. 

Topography  of  Cortical  Areas  of  the  Cerebrum.  The  Rolandic  or 
sensori-motor  area,  which  on  stimulation  experimentally  or  by  pathological 
processes  gives  rise  to  localized  movements  of  various  parts  of  the  body,  is 
situated  for  the  most  part  in  the  ascending  frontal  convolution  entirely  in 
front  of  the  fissure  of  Rolando,  and  also  to  a  less  extent  in  the  posterior  parts 
of  the  horizontal  frontal  convolutions.  Various  methods  have  been  employed 
to  find  the  fissure  of  Rolando,  and  it  is  as  well  to  use  more  than  one  in 
practice,  and  if  the  results  differ,  to  strike  an  average. 

(1)  The  upper  end  of  the  fissure  of  Rolando  is  half  an  inch  behind  the 
mid-naso-mial  point,  and  it  runs  down  nearly  parallel  to  the  middle  meningeal 
line,  or  at  an  angle  of  about  70  °with  the  anterior  part  of  the  naso-inial 
line.  This  angle  can  be  found  approximately  by  folding  the  corner 
of  a  sheet  of  paper  diagonally,  making  an  angle  of  45°,  and  then 
half  of  this  again,  making  an  angle  of  22|,  the  two  together  making  67J, 
which  is  near  enough  to  the  angle  required. 

(2)  Another  plan  is  to  draw  two  lines  vertically  up  from  Reid's  base- 
line, one  at  the  back  of  the  mastoid  and  the  other  just  in  front  of  the  external 
auditory  meatus,  and  then  join  the  points  where  the  posterior  line  cuts  the 
naso-inial  line  and  the  anterior  cuts  the  Sylvian  line.  The  line  thus  drawn 
represents  the  fissure  of  Rolando.  If  the  strip  of  brain  one  inch  wide  in 
front  of  the  Rolandic  fissure  be  divided  into  thirds  the  upper  third  represents 
movements  of  the  leg,  the  toes  being  uppermost  and  the  hip  below.  The 
middle  area  represents  the  arm,  the  shoulder  being  above  the  fingers  below. 

The  lower  third  of  the  strip  represents  the  movements  of  the  neck  and 
face  and  motor-speech.  Movements  of  the  eyes  and  head  are  in  the  posterior 
part  of  the  mid-frontal  convolution. 

(3)  The  parietooccipital  fissure,  which  only  comes  on  to  the  external 
surface  of  the  hemisphere  to  a  small  extent,  is  situated  at  the  lambda  or 
posterior  end  of  the  Sylvian  line,  and  the  portion  of  the  cerebrum  between 
this  and  the  inion,  i.e.  the  occipital  pole  of  the  cerebrum,  represents  on 
each  side  half  the  field  of  vision,  and  affection  of  this  part  of  the  brain 
causes  hemianopia. 

(4)  The  centre  for  visual  speech  around  the  angular  gyrus  is  indicated 
on  the  surface  by  the  point  where  the  line  joining  the  upper  end  of  the 
meningeal  line  and  the  a-terion  cuts  the  Sylvian  line,  i.e.  is  around  the 
posterior  end  of  the  Sylvian  fissure. 

(5)  The  centre  for  auditory  speech  is  in  the  parallel  convolution  below 
the  Sylvian  fissure  and  hall-way  along  this,  about  an  inch  and  a  half 
behind  the  lower  end  of  the  Rolandic  fissure. 

(6)  The  centre  for  taste  and  smell  are  situated  in  the  anterior  pole  of 
the  temporal  lobe,  an  inch  behind  the  external  angular  process  of  the  frontal 
bone. 


582  A  TEXTBOOK  OF  SURGERY 

General  Diagnosis  of  Cerebral  Affections.  Whether  caused  by 
alterations  of  intracranial  pressure  affecting  tin1  general  or  local  circulation 
oi  to  other  conditions,  the  symptoms  may  be  divided  into  general  and 
local. 

General  Signs.  (1)  Psychic  Effects.  The  mental  condition  may  alter 
in  two  directions,  either  towards  increased  activity  or  in  the  direction  of 
diminished  activity  or  lethargy. 

(a)  In  the  former  condition  the  patient  is  restless,  cannot  apply  his 
mind  for  more  than  a  short  time  to  any  occupation,  is  irritable,  unable  to 
sleep,  or  suffers  from  delirium,  and  may  be  maniacal.  Of  this  condition 
cerebral  irritation,  found  in  cases  where  the  brain  has  been  lacerated,  is  a 
marked  example,  as  are  the  neurasthenic  states  so  often  following  on  injuries 
of  the  brain,  in  which  case  the  condition  is  more  chronic  and  less  urgent. 

(b)  In  the  second  category  we  find  varying  grades  of  mental  dullness 
and  obscuration.  In  the  less  marked  degrees  the  patient  is  mentally  sluggish, 
takes  time  to  answer  questions,  and  takes  no  interest  in  passing  events. 
In  more  marked  cases  the  patient  may  be  stuporous  or  somnolent,  which 
last  condition  may  pass  into  complete  coma.  In  the  comatose  state  the 
patient  is  completely  unconscious  with  stertorous  breathing  :  in  severe  cases 
there  is  no  corneal  reflex,  fixed  dilated  pupils  and  general  flaccid  paralysis. 
This  condition  may  be  due  to  various  causes,  including  toxaemic  states, 
e.g.  uraemia  or  opium-poisoning,  but  in  surgical  practice  proper  is  usually 
due  to  increased  intracranial  pressure,  the  milder  stages  being  instanced 
by  the  earlier  cases  of  cerebral  abscess,  the  more  severe  grades  by  intra- 
cranial haemorrhage  or  the  final  end  of  cerebral  abscess. 

(2)  Headache.  This  in  itself  is  but  slender  evidence  of  cerebral  mischief, 
being  often  due  to  some  blood  condition,  digestive,  renal,  or  anaemic.  Errors 
of  ocular  refraction  are  a  fertile  source  of  headache,  and  every  possible  source 
must  be  excluded  before  the  headache  is  put  down  to  intracranial  disease. 

(3)  Offtic  neuritis,  or  oedema  of  the  optic  disc,  is  a  common  result  of 
raised  intracranial  pressure  and  most  often  found  in  cases  of  cerebral  tumour, 
1  «fi  often  in  those  of  abscess,  meningitis  sinus  thrombosis,  and  intra- 
cranial haemorrhage. 

(4)  Effects  on  the  Medullary  Centres,  (a)  Vomiting  from  stimulation 
of  the  vagal  centre  is  common  in  chronic,  slow  increase  of  intracranial 
pressure,  e.g.  from  cerebral  tumours,  but  does  not  occur  in  cases  of  rapid 
increase  of  intracranial  pressure  as  in  cases  of  haemorrhage,  though  it  is 
very  common  on  recovery  from  cerebral  concussion.  "  Cerebral  vomiting  " 
is  characterized  by  its  onset  having  no  relation  to  the  ingestion  of  food  or 
abdominal  pain  and  discomfort,  and  it  is  especially  frequent  in  growths  of 
the  cerebellum  and  pons. 

(6)  The  cardio-inhibitory  and  pressor  centres  are  also  affected.  In  a 
sudden  rise  of  intracranial  pressure  the  heart  is  slowed  and  the  blood- 
pressure  rises  :  there  is  also  slowing  of  the  pulse  in  cases  of  cerebral  abscess 
or  tumour,  but  in  the  later  stages  of  abscess  or  tumour  the  inhibitory  centre 
is  paralysed  and  the  pulse-rate  becomes  accelerated. 


GENERAL  DIAGNOSIS  OF  CEREBRAL  AFFECTIONS 

(c)  The  respiratory  centre  is  affected  by  increased  intracranial  pressure, 
the  vagal  reflex  being  first  cut  out,  and  the  centre  reacts  simply  to  the 
stimulus  of  carbon  dioxide  in  the  blood,  the  respiration  sinking  to  five  or  six 
a  minute,  while  in  many  instances  there  is  periodical  alteration  of  the 
respiratory  rhythm  (Cheyne-Stokes  respiration),  in  which  there  are  accelera- 
tions, retardations,  and  pauses  in  the  respiration  occurring  at  regular 
intervals. 

Localizing  Signs.  These  are  for  the  most  part  spasms  or  paralyses, 
though  in  some  instances  sensory  changes  help  in  localization. 

(1)  Ocular  Signs,  (a)  Loss  of  vision  in  the  corresponding  half  of  both 
visual  fields,  i.e.  right  or  left  points  to  a  lesion  in  the  cuneate  lobe  of  the 
occipital  pole  of  the  opposite  side. 

(b)  Loss  of  the  temporal  half  of  both  visual  fields  implies  a  lesion  of  the 
nasal  aspect  of  the  optic  nerves  at  the  chiasma,  usually  from  a  pituitary 
tumour. 

(c)  If  one  optic  nerve  is  pressed  on  or  cut  through,  the  eye  will  be  blind 
and  the  papillary  reflex  on  that  side  lost. 

(d)  Dilatation  of  the  pupil  points  to  intracerebral  pressure  on  the  same 
side,  the  third  nerve  being  paralysed,  usually  as  part  of  an  extradural 
haemorrhage  ;  later,  as  the  pressure  from  effused  blood  spreads,  the  other 
pupil  will  be  paralysed. 

(e)  Visual  aphasia,  i.e.  loss  of  power  to  understand  writing,  will  occur 
in  lesions  of  the  left  angular  gyrus. 

(2)  Auditory  Signs,  (a)  The  eighth  nerve  may  be  torn  across  in  fractures 
of  the  base  of  the  skull,  producing  internal  ear  deafness  (see  Diagnosis  of 
the  Disease  of  the  Ear). 

(b)  If  the  temporal  lobe  is  affected  deafness  of  the  opposite  side  may 
result,  and  if  the  lesion  is  on  the  left  side  auditory  aphasia  or  loss  of  under- 
standing of  speech  will  follow. 

(3)  Affections  of  the  motor  system  may  be  due  to  pressure  on  a  nerve, 
its  centre  inside  the  skull,  to  affections  of  the  sensori-motor  or  Rolandic 
area,  its  extension  into  the  internal  capsule  and  pyramidal  tract,  or  to 
affections  of  the  cerebellum. 

(a)  The  best  example  of  paralysis  of  one  nerve  is  that  of  the  third  found 
in  cases  of  a  large  temporo-sphenoidal  abscess  and  known  by  the  presence 
of  ptosis,  outward  deviation  of  the  eyeball,  and  dilatation  of  the  pupil. 

(b)  Crossed  paralyses  arise  from  affections  of  the  pons  and  cnis  above 
the  decussation  of  the  pyramids,  there  being  paralysis  of  the  cranial  nerves, 
e.g.  the  facial,  from  injury  of  its  nucleus  (i.e.  a  lower-segment  lesion)  on  the 
same  side  as  the  lesion,  combined  with  a  paralysis  of  the  opposite  side  of 
the  body  and  limb  muscles  from  pressure  on  the  pyramidal  tract  before  the 
fibres  cross. 

(c)  Lesions  affecting  the  Rolandic  area  may  produce  paralyses,  but 
more  commonly,  unless  very  rapidly  advancing,  the  initial  effect  is  irritation, 
causing  spasms  of  the  limb  or  part  of  the  limb  on  the  opposite  side  of  the 
body  represented  in  the  area  affected,  followed  later  by  paralysis  if  the  lesion 


58 1  A  TEXTBOOK  OF  SURGERY 

is  progressing  rapidly.  If  the  lesion  is  stationary  01  increasing  but  slowly, 
as  in  cases  of  growth,  sear,  or  callus  pressing  on  part  of  the  motor  area, 
the  train  of  symptoms  known  as  Jacksonian  epilepsy  will  develop.    The 

seizure  conies  on  as  fits  or  convulsions  which  always  originate  at  some 
definite  Bpot,  e.g.  the  face  or  thumb,  and  are  often  preceded  by  sensory 
abnormalities  such  as  pricking  or  tingling  of  the  part.  These  twitchings 
may  spread  till  the  whole  body  is  involved,  and  the  interval  between  such 
*'  fits  "'  varies  from  minutes  to  months.  Where  the  fits  become  very  much 
generalized  there  may  be  loss  of  consciousness,  but  insensibility  may  not 
occur  at  all.  If  the  lesion  is  spreading  rapidly,  as  in  cases  of  cortical  haemor- 
rhage, paralysis  follows  in  the  part  of  the  body  represented  in  the  cortex 
affected  and  increases  after  each  fit,  while  changes  in  sensation  both  of 
response  to  light  touch  and  also  muscular  sense  are  noted  in  the  affected 
region. 

(d)  Where  the  lesion  is  in  the  internal  capsule  there  is  no  spasm  or  fits 
but  an  advancing  paralysis  which  increases  more  rapidly,  since  the  nerve 
elements  lie  more  closely  together  than  in  the  cortex.  There  will  also  be 
loss  of  all  forms  of  sensation  in  the  opposite  half  of  the  body. 

(e)  Cerebellar  lesions  lead  to  deficiencies  in  equilibrium  of  the  patient : 
the  gait  is  peculiar,  staggering,  apparently  drunken,  irregular,  and  often 
zigzag,  and  the  patient  falls  to  the  side  of  the  lesion.  Vertigo  is  often 
prominent.  Inco-ordination  of  the  finer  movements  may  not  be  noted, 
but  those  of  more  gross  degree  are  often  deficient ;  thus  attempts  to  touch 
the  nose  with  the  finger,  the  eyes  being  closed,  or  to  rotate  both  arms  from 
the  shoulder  in  the  same  direction,  show  failure  of  co-ordination  on  the 
side  of  the  lesion.  There  may  be  paresis  of  the  limbs  on  the  affected  side, 
especially  the  arm,  and  the  reflexes  on  that  side  are  increased.  Syllabic 
speech  and  yawning  are  noted  in  cases  of  cerebellar  abscess,  and  sometimes 
retraction  of  the  head.  (Further  points  concerning  motion  and  sensation 
are  discussed  in  the  sections  on  the  Spinal  Cord  and  Peripheral  Nerves.) 

Examination  of  Cerebral  Cases.  Any  external  lesion  should  be 
carefully  noted,  as  well  as  escape  of  blood,  brain  or  cerebro-spinal  fluid 
from  nose,  ear,  mouth,  or  a  wound. 

The  cranial  nerves  should  be  examined  seriatim,  especially  the  oculo- 
motor and  optic,  as  changes  in  the  pupils  and  fundi  are  most  important. 

The  spinal  nerves  are  investigated  as  regards  fits  and  their  place  of 
onset,  paralyses,  and  tendon-reflexes. 

The  mental  state  should  be  noted  as  described  above,  as  well  as  the  pulse, 
respiration,  and  condition  of  the  sphincters. 

The  urine  is  examined  to  exclude  renal  disease  and  diabetes. 

Examination  is  made  of  old-standing  suppurative  lesions  likely  to  cause 
i  i  if  racranial  complications,  such  as  chronic  otitis  media  and  bronchiectasis. 

In  the  general  condition  it  will  be  noted  that  wasting  is  very  characteristic 
of  cerebral  abscess,  while  a  subnormal  temperature  is  also  common  in  this 
condition  ;  in  addition,  signs  of  metastatic  spread  of  cerebral  infections,  in 
the  shape  of  pyaomic  abscess  in  lungs,  joints  or  subcutaneously,  are  of  value. 


EXPLORATION  OF  THE  BRAIX  585 

Finally  lumbar  puncture  may  be  of  assistance,  both  in  diagnosis  and 
occasionally  in  treatment.  To  perform  lumbar  puncture  the  patient  is 
placed  on  the  side  and  the  knees  and  chin  brought  close  together.  This 
position  of  kyphosis  of  the  spine  opens  up  the  lamina?  and  spines  behind 
and  renders  the  spaces  between  these  larger.  A  stout  three-inch  exploring 
needle  is  introduced  in  the  mid-line  and  pushed  straight  forward  in  the 
horizontal  (transverse)  plane  of  the  body  between  the  spines  of  the  third 
and  fourth  lumbar  vertebrae  (level  with  the  crest  of  the  ilium).  In  most 
cases  cerebro-spinal  fluid  will  escape  without  using  the  syringe,  and  if  there 
is  much  intracranial  tension  may  spurt  out  freely.  Normal  cerebro-spinal 
fluid  is  quite  clear,  of  low  specific  gravity  and  reduces  Fehling's  solution. 
When  purulent  meningitis  is  present  the  fluid  is  more  or  less  turbid  and 
contains  polymorphonuclear  leucocytes  and  organisms.  In  tuberculous 
meningitis  the  fluid  is  but  little  altered  and  the  contained  cells  are  lympho- 
cytes, while  occasionally  tubercle  bacilli  may  be  found.  In  cases  of  intra- 
cranial bleeding  blood  may  be  found  in  the  fluid,  but  unless  in  fair  quantity, 
may  be  from  the  wound  made  in  puncturing. 

In  doubtful  cases  the  presence  of  pus  and  organisms  will  help  to  dis- 
tinguish between  cerebral  abscess  and  purulent  meningitis. 

Methods  of  Opening  the  Skull  to  Explore  the  Brain,  etc.  Owing 
to  the  hard  nature  of  their  protective  covering,  the  skull,  it  is  a  less  easy 
matter  to  explore  the  contents  of  the  cranium  than  those  of  the  abdomen, 
and  a  satisfactory  opening  in  the  skull  can  only  be  made  at  the  expense  of 
a  considerable  amount  of  hard  work  and  the  cost  of  some  time.  Therefore 
it  is  worth  considering  in  each  case  what  sort  of  opening  will  give  a  reasonable 
access,  in  order  to  explore  for  the  condition  under  treatment. 

It  is  also  important  that  the  instruments  used  enable  the  opening  to 
be  made  without  putting  too  much  strain  on  the  operator,  as  no  surgeon 
will  be  in  the  best  condition  to  deal  with  some  delicate  intracranial  operation 
after  half  an  hour's  hard  labour  in  forcing  his  way  through  an  ivory-like 
skull  with  inadequate  instruments. 

(1)  In  performing  an  operation  on  the  mastoid  antrum  it  will  often 
be  good  practice  to  expose  the  lateral  sinus  and  dura  over  temporo-sphenoidal 
lobe  or  cerebellum.  In  most  instances  of  this  nature  the  original  opening 
can  be  most  readily  enlarged  with  the  chisel  assisted  by  rongeur  forceps, 
which  takes  less  time  than  does  making  a  fresh  opening  with  the  trephine. 

(2)  The  trephine  is  useful  in  many  cases,  especially  if  the  seat  of  the 
lesion  can  be  estimated  with  fair  probability  or  where  opening  the  skull 
forms  part  of  some  set  operation,  such  as  removing  the  Gasserian  ganglion. 
A  trephine  of  one  inch  in  diameter  is  quite  large  enough,  as  the  labour 
of  working  a  larger  one  and  the  varying  thickness  of  the  skull  makes  the 
use  of  the  larger  trephines  tedious,  tiring,  and  likely  to  end  in  considerable 
laceration  of  the  dura.  The  trephine  should  be  of  the  Horsley  type  with 
a  detachable  centre-pin,  and  the  barrel  tapered  so  that  it  may  not  suddenly 
burst  through  into  the  interior  of  the  cranium. 

The  method  of  using  this  instrument  has  been  described  under  Trephining 


586 


A  TEXTBOOK  OF  SURGERY 


for  Fractured  Skull.  After  opening  the  skull  the  aperture  is  enlarged  with 
long-handled  rongeur  forceps  ;  with  good  instruments  a  large  hole  can 
be  made  in  a  few  minutes.  In  all  cases  a  skin-flap  of  adequate  size  is  first 
turned  down. 

(3)  Where  a  large  area  of  bone  needs  removal,  as  in  exploring  for  cerebral 
tumours,  the  above  method  may  still  be  used,  and  if  there  is  no  desire  to 
replace  bone  after  the  operation,  as  where  the  tumour  proves  irremovable 
and  a  large  aperture  is  needed  for  decompressive  purposes,  will  serve  very 
well.  Where,  however,  the  surgeon  desires  to  replace  the  skull  in  situ 
after  the  operation,  which  is  advisable  where  a  very  large  opening  has  to 
be  made,  the  scalp  and  skull  should  be  turned  down  together  in  the  form 


Fig. 


235.     A,  Raising  an  osteoplastic  flap,  showing  four  trephine  holes  partly  con- 
nected with  punch-forceps.     B,  Trephine  with  detachable  centre-pin. 


of  an  osteoplastic  flap.  In  any  case  a  flap  of  scalp  is  marked  out  of  Omega 
shape,  i.e.  with  the  free  end  considerably  larger  than  the  attached  base. 
This  flap  is  cut  down  to  the  bone  and  spurting  vessels  picked  up.  There 
are  various  methods  of  dividing  the  bone.  The  simplest  is  to  bore  four 
holes  with  small  trephine,  or  better,  because  quicker,  with  Doyen's  drill, 
which  is  worked  like  a  carpenter's  brace  and  will  only  cut  bone  but  not  the 
dura.  These  holes  are  at  the  four  corners  of  the  flap  and  have  to  be  con- 
nected together  on  the  three  free  sides  of  the  latter.  This  may  be  done  by 
threading  a  Gigli  saw  between  alternate  holes  and  cutting  out,  thus  dividing 
the  skull.  As,  however,  there  may  be  considerable  difficulty  in  passing 
the  saw  through  these  small  holes,  especially  if  the  skull  is  thick,  it  is  better 
to  connect  the  holes  by  cutting  a  groove  in  the  skull  with  punch-forceps  of 
the  De  Vilbiss  type.  After  the  three  long  sides  of  the  bone  flap  are  cut 
through,  the  short  base,  which  should  also  be  thin  (being  in  the  temporal 
region),  is  readily  fractured  by  forcibly  elevating  the  whole  osteoplastic 
flap  outwards.  Another  plan  is  to  use  a  guarded  circular  saw,  which  must 
be  rotating  backwards  or  it  will  jump,  and,  though  rapid,  there  is  considerable 
risk  of  cutting  the  dura  or  not  dividing  the  bone  deep  enough.     The  chisel 


CONCUSSION  587 

and  gouge  are  best  avoided  where  so  much  bone  has  to  be  divided,  as  con- 
cussion is  likely  to  be  caused. 

In  most  cases  it  will  be  sufficient  to  raise  the  skull  at  one  operation  and 
close  the  wound,  reopening  it  a  week  later,  incising  the  dura  and  exploring 
the  brain. 

Injuries  of  the  Brain  and  Meninges.  Injuries  of  the  meninges  are 
only  of  importance  in  so  far  as  they  affect  the  underlying  brain  either  from 
extravasation  of  blood,  formation  of  pus,  or  later  by  scar-tissue.  Injuries 
of  the  brain  may  be  open  (penetrating)  or  closed  (non-penetrating). 

The  following  affections  are  described  :  (1)  concussion,  (2)  compression, 
(3)  intracranial  haemorrhage,  (4)  laceration,  and  (5)  penetrating  wounds. 

Non-penetrating  Injuries  of  the  Brain.  Clinically,  injuries  of  the  brain 
fall  into  two  great  groups  according  as  to  whether  or  no  the  intracranial 
pressure  is  raised,  though  it  is  probable  that  few  cases  of  injury  persist  for 
much  time  without  some  compression  of  the  brain  being  present.  Accord- 
ingly we  have  the  two  clinical  conceptions  concussion  and  compression  of 
the  brain,  as  well  as  wounds  and  lacerations  of  the  organ,  which  may  be 
associated  with  concussion  and  compression  in  many  instances. 

(1)  Concussion  of  the  Brain  or  Cerebral  Shock.  Under  this  term 
are  grouped  cases  of  very  different  severity  and  often,  perhaps,  of  different 
pathology.  The  effect  of  sudden  insult  to  the  brain,  partly  by  direct  injury 
and  partly  by  upset  of  the  vascular  mechanism,  is  to  put  out  of  action 
more  or  less  of  the  brain,  and  we  may  distinguish  the  effect  on  the  higher 
psychic  and  volitional  centres  from  that  on  the  lower  medullary  centres. 
The  higher  centres  may  be  affected  alone,  but  the  more  primitive  medullary 
mechanisms  are  seldom  affected  unless  the  higher  centres  are  out  of  action. 
Thus  a  man  sustains  a  sharp  blow  on  the  jaw  or  temple  while  boxing  or 
playing  football,  and  is  perhaps  dazed  for  a  moment  or  staggers  and  falls, 
but  gets  up  immediately  and  continues  his  sport  as  before,  but  may  have 
no  recollection  of  what  happened  for  some  minutes  or  hours  after  the  injury 
or  may  behave  in  some  absurd  manner,  such  as  playing  in  the  wrong  direc- 
tion at  football.  Such  are  examples  of  concussion  where  the  higher  centres 
only  are  affected,  for  the  blood-pressure,  respiration,  &c,  must  be  in  good 
order  for  the  patient  to  carry  on.  If  the  injury  be  more  severe  there  is 
in  addition  affection  of  the  medullary  centres,  shown  by  prostration,  pallor, 
feeble  pulse,  shallow  respiration,  perhaps  vomiting,  and  as  a  rule  prolonged 
loss  of  consciousness.  In  other  words,  to  the  shock  of  the  higher  centres 
is  added  ordinary  shock  or  collapse,  and  in  some  instances  this  latter  effect 
may  be  so  severe  as  to  result  in  death.     {See  Shock,  p.  1 1 5.) 

Pathology.  This  is  largely  theoretical  and  based  on  what  is  known  of 
the  vascular  arrangements  of  the  brain.  Post-mortem  examinations  on 
cases  which  have  died  of  concussion  show  venous  engorgement  of  the  lungs 
and  abdominal  viscera,  suggesting  a  fall  of  blood-pressure  in  the  brain. 
In  some  cases  there  is  no  obvious  lesion  in  the  brain,  but  in  others  small 
punctiform  haemorrhages  or  lacerations.  The  affection  of  the  psychic  and 
volitional  centres  is  explained  by  the  alteration  in  circulation  caused  by 


A  TEXTBOOK  OF  SURGERY 

the  impact  on  the  brain,  while  the  condition  of  general  shock  is  attributed 

to  the  putting  out  of  court  of  the  vagus-inhibition  of  the  heart  and  the 
pressor  centre,  so  that  the  pulse  is  accelerated  and  small  and  the  blood- 
pressure  lowered,  accounting  for  the  small  flickering  pulse  of  concussion. 

Signs  and  Diagnosis.  1  n  well-marked  instances  the  patient  is  moderately 
unconscious,  but  can  usually  be  roused  by  shouting  or  shaking  for  a  few 
moments,  and  the  corneal  reflex  is  usually  present ;  in  severe  cases  the 
stupor  may  be  deep  and  the  reflex  absent.  The  patient  is  quiet,  the  surface 
of  the  body  and  face  cool,  pale  and  clammy,  the  pulse  rapid  and  feeble, 
the  respiration  shallow,  the  temperature  subnormal,  and  the  sphincters  of 
rectum  and  bladder  often  relaxed.  The  pupils  may  be  contracted  mode- 
rately and  react  to  light  ;  in  severe  cases  dilated,  fixed  pupils  may  be  noted, 
but  in  such  cases  there  is  generally  more  than  mere  concussion,  such  as 
laceration  or  compression  of  the  brain,  and  the  prognosis  is  grave.  The 
limbs,  though  relaxed,  are  not  toneless,  nor  is  there  the  difference  between 
the  various  limbs,  noted  in  cases  of  compression  when  paralysis  is  present. 
The  condition  of  unconsciousness  may  last  hours  or  days  (in  such  prolonged 
cases  the  general  shock  passes  off)  and  then  the  period  of  reaction  sets  in, 
or  signs  of  compression  of  the  brain  follow  or  of  laceration  and  cerebral 
irritability,  with  fits,  curling  up,  and  resentment  of  interference.  When 
recovery  is  commencing  the  surface  becomes  warmer  and  the  pulse  more 
full  and  slower,  while  vomiting  is  an  early  sign  of  return  to  the  normal. 
With  gradual  recovery  of  consciousness  the  patient  becomes  better,  but 
headache  is  likely  to  persist  for  some  days.  The  powers  of  the  brain  also 
take  some  time  to  recover,  such  as  being  able  to  read,  converse,  or  to  fix 
the  attention  for  prolonged  periods.  In  the  milder  examples  the  patient 
will  be  quite  well  in  a  few  days,  but  may  be  irritable  and  require  prolonged 
rest  from  brain-work.  For  in  a  good  many  instances  important  sequela? 
follow.  Thus  signs  of  cerebral  irritability  develop,  usually  due  to  lacera- 
tion of  the  brain  of  a  non-focal  nature,  or  a  neurasthenic  condition  may 
result,  shown  by  weakness  of  memory  and  vision,  loss  of  visual  accommoda- 
tion, irritability,  sleeplessness,  inability  to  fix  the  attention.  Such  cases 
may  become  worse,  ending  in  insanity,  or  the  brain  is  permanently  weak 
and  readily  affected  by  adverse  conditions,  such  as  small  doses  of  alcohol 
or  exposure  to  the  sun,  insufficient  to  affect  a  normal  brain.  Loss  of  memory 
for  the  events  after  an  accident  of  this  sort  is  common,  and  even  of  affairs 
which  have  happened  when  the  patient  appeared  to  be  quite  conscious  and 
rational.  These  sequelae  will  be  further  discussed  under  Traumatic  Neuras- 
thenia (p.  633). 

The  diagnosis  is  made  from  ordinary  shock  by  the  unconsciousness  and 
mental  obscuration  ;  from  cerebral  compression  by  the  rapid,  feeble  pulse, 
shallow,  non-stertorous  respiration,  by  the  pupil  being  as  a  rule  active  and 
the  conjunctival  reflex  present ;  from  the  various  intoxications  by  the 
much  less  depth  of  unconsciousness,  which  leads  the  latter  conditions  to 
be  confused  rather  with  the  coma  of  compression  than  the  stupor  of 
concussion. 


CEREBRAL  IRRITATION  589 

Treatment.  At  the  commencement  treatment  is  mainly  directed  to  the 
general  shock,  the  patient  being  made  warm  in  bed  with  warm  bottles,  but 
no  attempt  should  be  made  to  increase  the  blood-pressure  by  saline  infusions 
unless  the  collapse  be  very  severe  and  likely  to  prove  fatal ;  for  if  there 
is  any  laceration  of  the  brain  a  rise  in  the  blood-pressure  may  cause  intra- 
cranial haemorrhage  and  cerebral  compression.  When  the  initial  shock  has 
passed  off  the  patient  is  kept  on  a  low  diet  and  the  bowels  opened  with 
calomel,  till  recovery  of  consciousness  is  complete  and  headache  has  gone 
for  some  days.  It  is  well  to  keep  the  patient  in  bed  till  the  headache  is 
better,  and  he  should  not  return  to  work  for  some  weeks,  depending  on  the 
severity  of  the  injury  and  the  quality  of  the  work  to  be  done.  Thus  indoor 
brain- workers  should  be  kept  longer  at  rest  than  those  who  follow  a  healthy 
outdoor  employment.  Where  insensibility  persists  the  patient  must  be 
fed  with  nasal-  or  stomach-tube  if  too  deeply  unconscious  to  use  the  feeder, 
and  the  bowels  are  kept  open  with  enemata.  There  is  no  need  to  shave 
the  head  unless  it  is  decided  to  open  the  skull.  Ice-bags  are  traditional, 
but  fatuous.  Unconsciousness  may  persist  for  weeks  and  good  recovery 
take  place  if  the  nutrition  and  general  well-being  of  the  patient  are  cared 
for.  Unless  signs  of  focal  irritation  in  the  shape  of  fits  or  signs  of  com- 
pression develop,  there  is  nothing  to  be  gained  by  opening  the  skull. 

Delirium  of  the  tremulous  or  ordinary  types  is  very  common  in  these 
patients  when  recovering,  and  therefore  they  must  be  carefully  watched 
till  well  recovered,  especially  at  night. 

Cerebral  Irritation.  This  is  a  clinical  symptom-complex  often  following 
on  cases  of  severe  concussion,  and  probably  due  to  a  widespread  superficial 
but  non- focal  laceration  of  the  cortex,  and  pathologically  may  be  considered 
as  occupying  a  place  between  simple  concussion  and  laceration  of  the  brain. 

The  mental  and  bodily  attitude  of  the  patient  are  characteristic.  He 
lies  curled  up  in  a  ball  with  head,  spine,  thigh,  legs,  and  arms  all  flexed  and 
the  eyes  firmly  closed.  The  patient  lies  torpid  in  this  attitude  for  hours, 
but  may  be  restless  at  times  and  throw  himself  about.  He  will  take  liquid 
food  from  a  feeder  readily,  and  may  suffer  from  incontinence  of  urine  and 
fasces  or  retention  of  urine.  There  is  marked  photophobia,  the  pupils  are 
contracted  ;  the  temperature,  pulse,  and  body-surface  are  normal.  Although 
the  patient  is  torpid,  yet  he  very  much  resents  attention,  and  if  interfered 
with  scowls,  swears,  and  gnashes  his  teeth.  This  condition  may  last  several 
days  and  usually  ends  in  recovery.  The  patient  gradually  uncurls,  becomes 
less  irritable,  control  of  the  sphincters  is  regained,  and  he  will  feed  himself. 
The  mental  state  improves,  becoming  at  first  that  of  a  child — smiling  and 
laughing  at  trifles,  making  fatuous  remarks,  and  needing  instruction  as 
to  the  names  of  things,  or  even  may  need  to  re-learn  the  art  of  speech. 
Recovery  will  be  prolonged,  and  the  condition  may  pass  into  one  of  perma- 
nent mental  weakness.  In  other  cases  signs  of  compression  arise  or  focal 
irritation  with  fits  and  paralyses. 

Treatment.  These  cases  require  nursing,  feeding,  attention  to  the 
bowels   and    bladder,    prolonged    rest,    and    gradual    return    to    cerebral 


\  TK XT HOOK  OF  SCROKRY 

functions  such  as  reading,  writing,  &c,  and  months  may  elapse  before  the 
patient  is  tit   for  work. 

Where  focal  signs  01  compression  occur  the  skull  must  be  opened. 

(2)  Acute  Compression  of  the  Brain.  This  clinical  term,  some- 
times called  simply  compression,  refers  to  eases  where  the  intracranial 
pressure  is  suddenly  raised,  as  by  depression  of  part  of  the  calvarium, 
extravasation  of  blood,  or  occasionally  by  formation  of  pus  inside  the  skull. 
Other  cases  where  the  pressure  inside  the  skull  is  raised  gradually,  as  by 
growth  of  tumour  or  formation  of  a  cerebral  abscess,  present  different  signs 
in  some  respects. 

Tims  in  acute  compression  vomiting  is  rare,  while  it  is  a  characteristic 
feature  of  chronic  compression  by  tumour-growth.  Coma  occurs  early  in 
acute  concession,  but  only  in  the  last  stages  of  the  chronic  condition. 

The  causes  of  acute  compression  of  the  brain  are  : 

(1)  Depressed  fractures,  though  in  these  cases  it  is  often  the  associated 
intracranial  haemorrhage  that  causes  most  of  the  pressure. 

(2)  Intracranial  haemorrhage,  from  rupture  of  meningeal  arteries,  veins, 
and  sinuses  or  cerebral  vessels  in  cases  where  the  brain  is  lacerated. 

(3)  OZdema  spreading  about  a  haemorrhage,  tumour,  or  abscess  of  the 
brain  owing  to  an  upsetting  of  the  arrangements  for  drainage  of  the  cerebro- 
spinal fluid. 

(■i)  Intracranial  suppuration  may  cause  such  signs,  but  more  often 
those  of  chronic  compression. 

Signs  of  Acute  Compression.  The  signs  described  below  refer  to  well- 
marked  cases.  In  less  severe  grades  the  coma  may  be  replaced  by  somno- 
lence, the  pulse  may  not  be  much  slowed  and  the  respiration  may  not  be 
stertorous,  and  if  the  pressure  ceases  to  increase,  as  where  intracranial 
bleeding  ceases,  the  blood-supply  of  the  brain  may  accommodate  itself  to 
the  diminished  space  inside  the  cranium  and  the  condition  improve  without 
developing  the  picture  of  severe  acute  compression.  In  well-marked 
instances  the  patient  is  in  a  condition  of  coma,  i.e.  of  deep  insensibility,  quite 
beyond  rousing  by  shouting,  pinching.  &c.  Tin1  respiration  is  slow  and 
stertorous,  the  cheeks  puffing  in  and  out,  and  the  palate  flapping  from 
paralysis  of  its  muscles.  As  the  condition  advances  Cheyne-Stokes 
alterations  in  the  respiratory  rhythm  are  noted  and  are  of  grave  significance, 
pointing  to  collapse  of  the  respiratory  centre.  The  pulse  is  at  first  slow, 
full  and  forcible,  with  rise  of  blood-pressure,  but  later  becomes  weak  and 
irregular  as  vagus-inhibition  is  paralysed  and  the  pressor  centre  of  the 
medulla  becomes  paralysed.  The  temperature  may  be  normal  or  con- 
siderably raised,  the  latter  condition  suggesting  laceration  of  the  basal 
nuclei. 

The  pupils  show  changes  which  are  important  in  assisting  to  locate 
the  site  of  the  lesion.  In  advanced  cases  they  are  both  dilated  and  paralysed 
(insensitive  to  light).  In  early  cases,  however,  the  pupil  on  the  side  where 
compression  commences  is  slightly  contracted  and  sensitive  to  light ;  later, 
as  the  pressure  increases,  this  pupil  becomes  paralysed  and  dilated,  becoming 


ACUTE  COMPRESSION  OF  THE  BRAIN  591 

insensitive  to  light,  while  the  pupil  on  the  opposite  side  is  still  of  normal 
size  and  reacting ;  still  later  the  second  pupil  also  becomes  dilated  and 
insensitive  (Hutchinson).  Paralysis  of  the  limbs  will  also  be  noted,  and 
may  assist  in  locating  the  lesion.  In  severe  and  advanced  conditions  all 
the  limbs  are  paralysed,  but  in  earlier  cases  it  will  be  found  that  if  the  arms 
and  legs  are  lifted  and  allowed  to  fall,  that  on  one  side  they  are  much  more 
flaccid  than  on  the  other,  pointing  to  a  lesion  on  the  opposite  side  to  the 
flaccidity  ;  in  some  instances  there  is  abnormal  rigidity  of  the  limbs  on 
one  side,  pointing  to  a  lesion  on  the  opposite  side  of  the  brain.  There  may 
be  localized  fits  or  general  convulsions.  The  sphincters  are  affected,  the 
usual  condition  being  retention  of  urine  and  incontinence  of  faeces. 

Diagnosis.  Acute  compression  is  readily  distinguished  from  concussion 
by  the  depth  of  insensibility,  the  paralyses,  slow  pulse,  stertorous  respira- 
tion, and  the  pupillary  changes. 

Conditions  much  more  important  and  often  difficult  to  diagnose  from 
compression  are  other  cerebral  states  causing  coma,  and  various  intoxications 
and  auto-intoxications. 

When  a  definite  history  of  injury  to  the  head  is  obtained  diagnosis 
is  usually  easy,  but  if  a  patient  is  picked  up  unconscious  with  no  history 
diagnosis  may  often  be  difficult,  if  no  obvious  injury  to  the  skull  is  present. 
Conditions  most  likely  to  be  confused  with  acute  traumatic  compression 
are  : 

(1)  Cerebral  affections. 

(a)  Apoplexy  from  haemorrhage,  thrombosis,  or  embolism. 
(6)  Terminal  stages  of  cerebral  abscess  or  tumour, 
(c)  The  post-epileptic  state. 

(2)  Intoxications  from  narcotics,  especially  alcohol  and  opium  ;  heat- 
stroke. 

(3)  Auto-intoxications,  uraemia  and  diabetes,  rarely  cholaemia. 

A  complete  examination  is  needed  to  avoid  error.  The  odour  of  the 
breath  will  detect  alcohol,  or  acetone  in  diabetics.  The  urine  should  always 
be  drawn  off  and  tested,  and  will  show  sugar,  acetone,  and  diacetic  acid  in 
diabetics,  while  in  uraemia  the  small  amount,  low  specific  gravity,  with 
possibly  albumen  or  casts,  will  point  to  renal  disease.  The  vomit,  if  present, 
should  be  tested  for  drugs,  and  in  doubtful  cases  the  stomach  should  be 
washed  out,  as  this  will  do  no  harm  where  the  brain  is  injured  and  may 
be  the  salvation  of  a  case  of  narcotic  poisoning,  besides  leading  to  detection 
of  the  poison. 

The  skull  should  be  examined  for  contusion  or  fractures,  especially  in 
the  temporal  regions,  while  signs  pointing  to  fracture  of  the  base  should 
be  looked  for.  The  tongue  may  be  bitten  in  epileptics.  The  pupils  are 
contracted  in  cases  of  haemorrhage  into  the  pontine  region  and  in  opium- 
poisoning,  while  in  the  last  condition  especially  respiration  is  slowed  down 
to  as  few  as  four  per  minute.  The  depth  of  coma  will  be  less  in  heat- 
stroke and  the  post-epileptic  state.  Hemiplegia  and  alteration  of  the  reflexes 
will  suggest  a  cerebral  lesion  rather  than  an  intoxication.     It  should  be 


A  TEXTBOOK  OF  SURGERY 

clearly  recognized  that  two  different  conditions  may  be  present  together, 
e.g.  a  patient  may  fall  in  an  apoplectic  or  epileptic  tit  and  injure  the  skull, 
or  a  patient  with  alcohol  in  the  stomach  (not  necessarily  drunk)  may  fall 
and  sustain  intracranial  haemorrhage  or  after  such  a  fall  may  be  given 
brandy  by  some  good  but  mistaken  Samaritan.  In  doubtful  alcoholic  cases 
the  stomach  should  be  washed  out  -  such  treatment  being  harmless  to  cases 
ssion,  while  usually  serving  to  revive  the  intoxicated.  When 
thorough  examination  has  been  made,  the  only  conditions  likely  to  be 
confused  are  apoplexy  and  traumatic  compression,  which  is  not  surprising, 
seeing  the  close  resemblance  in  pathology.  A  huge  heart,  thick  arteries, 
and  high-tension  pulse  are  in  favour  of  apoplexy  from  cerebral  haemorrhage, 
while  a  cardiac  lesion  will  suggest  the  possibility  of  embolism. 

Treatment.  "Where  the  signs  are  well  marked  there  shoidd  be  no  hesita- 
tion in  opening  the  skull  unless  the  patient  is  too  bad  to  be  likely  to  stand 
operation.  The  side  on  which  to  make  the  opening  will  be  determined  by 
the  paralysis  and  pupillary  changes,  i.e.  will  be  opposite  the  paralysis  and 
on  the  side  where  the  pupil  first  became  dilated.  In  most  instances  a 
large  removal  of  bone  should  be  made  in  the  temporal  region,  splitting  the 
temporal  muscle  ;  but  where  there  is  a  depressed  fracture  or  where  a  large 
haematoma  suggests  the  presence  of  this,  exploration  should  be  guided  by 
the  condition  of  the  skull.  Operative  treatment  of  compression  is  further 
discussed  under  Intracranial  Haemorrhage,  Depressed  Fractures,  &c. 

(3)  Intracranial  Hemorrhage.  This  subject  is  allied  to  that  of 
acute  compression  of  the  brain,  of  which  indeed  it  is  the  most  common 
source. 

Intracranial  bleeding  may  be  extradural  or  intradural,  in  the  latter  case 
being  usually  associated  with  laceration  of  the  brain. 

(a)  Extradural  H  j.morrage.  Bleeding  outside  the  dura  is  the  result 
of  injuries  of  the  venous  sinuses,  meningeal  vessels,  both  arteries  and  veins, 
and  the  internal  carotid  artery.  If  the  wounded  vessel  communicates  with 
the  surface  by  a  wound  the  bleeding  will  be  mostly  external  and  the  effect 
on  the  brain  small,  while  if  shut  in  by  the  intact  cranium  the  result  will  be 
acute  cerebral  compression. 

(1)  Injuries  of  Venous  Sinuses,  causing  Hamorrhage.  The  sinuses  are 
usually  torn  across  in  fractures,  especially  when  depressed  or  punctured, 
e.g.  in  bullet- wounds. 

The  effects  vary  ;  a  depressed  spicule  of  bone  may  plug  the  sinus  and 
prevent  bleeding  till  it  is  elevated  at  operation,  when  copious  venous  bleed- 
ing takes  place.  This  can  be  readily  controlled  by  pushing  gauze  between 
the  skull  and  the  sinus,  so  compressing  it  on  either  side  of  the  puncture. 
In  other  cases  the  effused  blood  will  strip  up  the  dura  from  the  skull,  forming 
a  large  collection  and  causing  cerebral  compression.  In  yet  other  cases 
there  will  be  a  profuse  escape  of  venous  blood  through  a  depressed  or  punc- 
tured fracture  calling  tor  plugging  with  gauze,  while  the  skull  is  quickly 
opened  with  trephine.  &c.,  ami  the  sinus  obliterated  as  before  by  plugging 
between  the  skull  and  the  sinus.     Much  more  rarely  blood  may  escape  on 


EXTRADURAL  HEMORRHAGE  593 

the  deep  surface  of  the  dura,  leading  to  intradural  haemorrhage.  Where 
there  is  a  wound  which  is  not  aseptic,  infective  thrombosis  of  the 
sinus  may  take  place  ;  this  is  described  later  (see  Intracranial  Inflam- 
mations). 

(2)  Rupture  of  the  Internal  Carotid  Artery  inside  the  Skull.  This  occurs 
in  fractures  of  the  base  cf  severe  character,  and  if  the  rupture  is  complete 
will  be  rapidly  fatal  from  severe  and  rapid  cerebral  compression.  Partial 
rupture  from  injuries  is,  however,  not  uncommon,  usually  leading  to  a 
communication  with  the  cavernous  sinus,  forming  an  aneurysmal  varix, 
which  is  the  most  common  cause  of  acquired  pulsating  exophthalmos.  If 
not  immediately  fatal,  ligature  of  the  common  carotid  in  the  neck  is  indi- 
cated where  the  condition  is  diagnosed,  which  is  seldom  the  case.  For 
pulsating  exophthalmos,  arising  from  this  cause,  ligature  of  that  carotid 
which  controls  the  pulsation  gives  excellent  results. 

(3)  Middle  Meningeal  Haemorrhage.  The  usual  cause  of  extradural  or 
subcranial  haemorrhage  is  a  rupture  of  the  middle  meningeal  artery  or  of 
the  meningeal  arteries  and  veins  in  its  neighbourhood,  for  in  a  good  many 
cases  diagnosed  as  such  the  main  trunk  or  the  large  anterior  and  posterior 
divisions  are  not  torn  but  the  bleeding  comes  from  the  small  arteries  and 
veins,  which  are  branches  of  the  middle  meningeal  artery  and  vein.  This 
vascular  lesion  may  accompany  simple  depressed  or  compound  fracture  or 
occur  apart  from  fractures.  The  result  is  a  large  and  growing  collection 
of  blood  between  the  cranium  and  dura,  which,  being  forced  from  the 
small  vessels  into  the  large  space,  has  the  powerful  action  of  the  Bramah 
press  and  produces  compression  of  the  brain. 

Signs.  In  a  good  many  instances  the  clinical  course  is  characteristic. 
There  will  be  some  initial  concussion,  which  passes  off,  and  the  patient 
appears  to  be  recovering  like  any  case  of  slight  concussion.  This  period  of 
recovery  may  last  some  hours  or  even  a  day  or  two,  and  is  known  as  the 
"  lucid  interval."  The  signs  of  compression  gradually  develop,  commencing 
with  drowsiness,  passing  into  coma  with  paralysis  of  the  opposite  side  of 
the  body.  In  other  cases,  however,  the  condition  is  less  obvious,  for  the 
concussion  may  be  severe  and  pass  into  compression  without  any  lucid 
interval,  or.  if  the  haemorrhage  is  very  free,  may  come  on  early,  or  the 
hemorrhage  may  be  combined  with  other  lesions  such  as  laceration  of  the 
brain,  in  all  of  which  conditions  the  prognosis  is  less  favourable  than  in 
the  simpler  cases.  Signs  which  help  to  differentiate  this  from  other  forms 
of  cerebral  compression  are  : 

(a)  The  lucid  interval. 

(6)  Signs  of  local  injury  and  bruising  in  the  temporal  region,  a  haematonia 
forming  either  from  bruising  of  the  tissues  over  the  cranium  at  the  site  of 
injury  or  from  blood  leaking  through  a  fracture  from  the  subcranial  space 
to  beneath  the  temporal  muscles.  Sometimes  a  simple  or  compound 
depressed  fracture  may  be  detected. 

(c)  Exophthalmos  and  ecchymosis  under  the  ocular  conjunctiva  may  be 
found  as  described  in  Fractures  of  the  Base  of  the  Skull  (p.  573). 
r  38 


594  A  TEXTBOOK  OF  SURGERY 

(d)  From  the  position  of  the  middle  meningeal  artery  over  the  Rolandic 

area  escape  of  blood  may  irritate  the  subjacent  cortex  and  cause  twitchings 
of  the  arm  and  lace  on  the  opposite  side,  followed  by  paralysis  and  preceding 
the  onset  ot  coma. 

(e)  The  pupillary  changes  described  under  Cerebral  Compression  are 
mostly  found  in  this  lesion,  viz.  dilatation  and  paralysis  of  the  pupil  on  the 
side  of  injury  and  opposite  to  the  twitchings  and  paralysis,  caused  by 
pressure  on  the  third  nerve  as  it  lies  in  the  wall  of  the  cavernous  sinus. 

(f)  If  the  posterior  division  of  the  middle  meningeal  artery  is  torn,  the 
effusion  of  blood  will  be  further  back  and  paralysis  of  the  opposite  side  of 
the  body  will  come  on  without  preliminary  twitches  or  fits,  from  pressure 
on  the  internal  capsule  before  the  cortex  is  affected. 

From  these  signs  it  will  be  possible  in  many  instances  to  locate  the 
side  of  injury  and  to  be  fairly  certain  that  the  bleeding  is  from  the  meningeal 
vessels,  but  where  the  case  is  only  seen  late  with  complete  paralysis  of  both 
sides  and  the  pupils  both  dilated  and  fixed,  it  may  be  necessary  to  open 
both  sides  of  the  skull  before  the  lesion  is  found. 

Treatment.  Early  operation,  turning  out  clots,  and  tying  bleeding- 
points  is  the  only  hope  of  saving  the  patient.  The  scalp  is  shaved  and 
purified,  and  a  point  is  marked  on  the  skull  by  driving  a  sharp  punch 
through  the  scalp  and  temporal  muscle  at  a  point  an  inch  and  a  half  behind 
the  external  angular  process  of  the  frontal  bone  and  an  inch  and  a  half  above 
the  zygoma  ;  or  the  point  at  the  commencement  of  the  middle  meningeal 
line  (Chiene)  maybe  employed.  A  suitable  flap  of  scalp  and  temporal  muscle 
is  turned  down  from  the  temporal  region  to  command  this  point  and  a  hole 
bored  with  an  inch  trephine,  placing  the  centre-pin  in  the  small  hole 
previously  marked  on  the  skull.  When  the  circle  of  bone  is  removed  the 
anterior  branch  of  the  artery  is  accurately  hit  off.  If  the  rupture  is  nearer 
the  origin  of  the  vessel  the  aperture  is  enlarged  with  rongeur  forceps  till  the 
foramen  spinosum  in  the  base  of  the  skull  is  reached,  and  this  may  be 
plugged  to  occlude  the  vessel,  or  a  suture  may  be  passed  round  the  vessel 
as  it  lies  in  the  dura  (clots  are,  of  course,  previously  removed).  Where  no 
rupture  of  a  large  branch  can  be  made  out  any  bleeding-points  are  tied 
and  the  wound  closed  with  temporary  drainage.  Bleeding  from  smaller 
branches  will  usually  cease  if  this  be  done,  since  the  pressure  has  been 
removed  from  the  brain  by  removing  the  clot,  and  this  will  induce  a  fall 
of  general  blood-pressure  and  so  help  to  promote  clotting  in  the  vessels. 
Relief  of  intracranial  pressure  is  the  all-important  point  in  this  operation. 

The  posterior  branch  may  be  found  by  trephining  over  a  horizontal 
line  drawn  back  from  the  middle-meningeal  point  (Chiene),  but  as  diagnosis 
of  this  condition  is  uncertain  and  in  most  instances  the  anterior  and  main 
vessels  will  have  been  explored  first,  it  will  generally  be  simpler  to  extend 
the  aperture  in  the  skull  back  with  rongeur  forceps  than  to  make  a  separate 
and  fresh  opening  with  the  trephine. 

(b)  Intradural  H^morrage.  This  generally  results  from  rupture  of 
vessels  of  the  cortex  cerebri  or  pia  mater,  and  thus  is  commonly  associated 


INTRADURAL  HEMORRHAGE  595 

with  laceration  of  the  brain.  Less  often  the  condition  is  due  to  rupture  of 
venous  sinuses  or  to  the  meningeal  vessels  giving  way  on  their  deep  surface. 
Like  laceration  of  the  brain,  intradural  haemorrhage  is  often  due  to  contre- 
coup,  the  brain  swinging  across  the  cranial  cavity  and  impinging  with 
sufficient  violence  on  the  opposite  side  to  cause  rupture  of  blood-vessels. 
The  blood  may  be  effused  in  a  thin  layer  over  the  surface  of  the  cerebrum 
or  in  a  more  localized  mass,  which  later  organizes  into  fibrous  tissue,  the 
central  part  becoming  softened  and  filled  with  cerebro-spinal  fluid  and 
broken-down  blood-clot,  being  then  known  as  an  "  arachnoid  cyst."  Such 
a  cyst  is  a  cavity  in  the  arachnoid,  the  walls  of  which  are  stained  brown 
with  haematin,  containing  serum  or  cerebro-spinal  fluid  and  sometimes 
communicating  with  a  translucent  swelling  outside  the  skull  bv  means  of 
the  aperture  of  a  small  fracture,  when  it  forms  one  variety  of  traumatic 
cephal-hydroccele.  Organization  of  the  more  diffuse  forms  of  intradural 
bleeding  leads  to  thickening  of  the  meninges  and  may  account  for  some  of 
the  later  effects  of  severe  concussion,  such  as  headaches,  mental  weakness, 
&c. 

Signs.  The  slighter  cases  are  hardly  diagnosable  from  the  concussion 
or  laceration  of  the  brain  of  which  they  form  a  part. 

Where  the  haemorrhage  is  large  and  rapidly  poured  out.  the  patient 
presents  early  the  signs  of  cerebral  compression  without  localizing  signs, 
and  the  only  thing  to  be  done  is  to  open  the  skull  widely  and  also  the  dura 
if  blood  can  be  seen  shining  darkly  through  the  latter.  This  may  relieve 
the  compression,  but  as  the  bleeding-point  can  seldom  be  found,  the  outlook 
in  such  cases  is  not  good.  Where  the  haemorrhage  is  less  severe  yet  persis- 
tent, the  case  presents  considerable  resemblance  to  one  of  middle-meningeal 
haemorrhage  ;  there  will  be  initial  concussion  followed  by  a  lucid  interval, 
which  is  often  long.  Then,  if  the  escaping  blood  presses  on  the  motor  area, 
fits  commencing  on  the  opposite  side  of  the  body,  followed  by  increasing 
paralysis,  come  on  and  coma  gradually  supervenes.  If  the  bleeding  is 
over  some  other  part  of  the  brain  there  may  be  local  signs  (visual  or 
aphasic  changes,  &c.)  which  may  help  to  localize  the  lesion,  or  there  may  be 
simply  advancing  coma. 

Diagnosis.  From  extradural  haemorrhage  and  laceration  of  the  brain 
this  is  often  impossible  before  the  skull  is  opened,  and,  as  has  been  pointed 
out,  intradural  haemorrhage  often  arises  from  laceration  of  the  brain.  The 
occurrence  of  a  long  lucid  interval  and  late  incidence  of  fits,  paralysis  and 
coma,  preceded  by  drowsiness  and  irritability,  distinguish  it  from  the 
former  and  point  to  laceration  of  the  brain. 

Treatment.  The  minor  cases  recover  under  expectant  treatment,  but 
these  can  hardly  be  diagnosed  with  much  accuracy.  The  indications  for 
operation  are  fits,  followed  by  paralysis,  or  stupor  and  incipient  coma.  If 
the  escaping  blood  is  ploughing  up  the  brain,  the  sooner  this  is  stopped  the 
less  scarring  will  result  and  the  less  chance  there  is  later  of  Jacksonian 
epilepsy  developing.  It  is  important  to  recognize  that  the  injury  may  be 
due  to  contre-coup  and  that  the  side  of  the  skull  to  open  is  that  opposite 


A  TEXTBOOK  OF  SURGERY 

in  tin*  fits  and  paralysis,  and  not  necessarily  that  on  which  there  is  a  scalp- 
wound  or  hematoma,  and  as  no  fracture  or  other  lesion  may  be  present 
it  is  far  safer  to  localize  by  the  cerebral  signs  than  by  those  in  the  scalp. 

Operation.  The  skull  is  opened  widely  over  the  motor  or  other  focal 
area,  and  as  the  operation  is  essentially  one  of  decompression  the  skull 
may  as  well  be  removed  with  trephine  and  rongeur  forceps  as  an  osteo- 
plastic flap  turned  down. 

The  dura  when  exposed  will  bulge  into  the  wound,  there  being  no  extra- 
dural clot  ;  pulsation  of  the  dura  is  diminished  or  absent.  The  dark  blood 
may  be  seen  through  the  dura,  but  in  any  case  bulging  dura  should  be 
opened,  as  the  compressing  agent  may  not  be  blood  but  serum,  and  this 
measure  will  certainly  relieve  pressure,  i.e.  will  "  decompress  "  the  brain. 
Where  no  signs  of  bleeding  are  found  the  other  side  should  at  once  be  opened. 
When  clots  are  found  they  are  removed  and  bleeding-points  secured  by 
ligatures  or  undersewing,  which  may  not  be  an  easy  matter  ;  failing  these 
measures  a  gauze  pack  steeped  in  adrenalin  may  be  used,  and  we  have 
found  this  very  efficacious  in  a  severe  case  of  intradural  haemorrhage  with 
laceration  of  the  brain.  The  dura  is  closed  as  far  as  possible  and  the  scalp 
sutured,  being  drained  for  twenty-four  hours  ;  no  replacement  of  bone  is 
necessary,  or  in  many  cases  desirable.  The  poor  results  in  these  cases, 
if  operated  on  later  when  Jacksonian  epilepsy  has  developed,  is  a  great 
argument  in  favour  of  early  operation. 

This  lesion  may  occur  to  new-born  infants  during  difficult  labour  from 
pressure  of  forceps,  and  if  localizing  signs  are  present  the  skull  should  be 
opened  at  once  and  clots  removed,  for  there  is  grave  risk  if  the  child  recovers 
of  the  development  of  spastic  upper-segment  paralysis  (Little's  disease) 
or  mental  weakness,  blindness,  deafness,  &c,  may  follow. 

(c)  Intracerebral  Hemorrhage.  This  condition,  usually  known  as 
apoplexy,  results  frcm  giving  way  of  an  artery  inside  the  brain,  and  is  due 
to  high  blood-pressure  and  diseased  condition  of  the  vessels,  and  very  rarely 
from  injuries.  These  cases  are  usually  considered  outside  the  scope  of  surgery, 
but  successful  instances  are  reported  by  Hudson  of  decompressive  opera- 
tions on  such  cases,  the  effused  blood  being  evacuated  by  puncturing  the 
brain  two  inches  above  the  external  auditory  meatus  after  making  a  large 
aperture  in  the  skull.  As  the  more  severe  of  these  cases  are  hopeless  under 
medical  treatment,  there  seems  no  reason  why  surgical  measures  should  not 
be  applied  to  selected  cases. 

(4)  Laceration  of  the  Brain,  or  Non-penetrating  Wounds.  Under 
the  headings  Concussion,  Compression,  and  Cerebral  Irritation  we  have 
discussed  the  finer  sorts  of  cerebral  injury,  whether  from  shock  or  pressure  ; 
it  remains  to  consider  the  more  gross  lesions  in  which  the  tearing  of  brain- 
substance  is  macroscopic.  Such  wounds  of  the  brain  may  practically  be 
divided  into  those  not  associated  with  any  compound  depressed  or  punc- 
tured fracture  and  those  in  which  such  a  fracture  exists. 

Lacerations  or  non-penetrating  wounds  result  from  falls  and  blows  on 
the  skull,  and  may  or  may  not  be  associated  with  fracture  of  the  latter. 


LACERATION  OF  THE  BRAIN  597 

It  is  important  to  recognize  that  severe  injuries  of  the  brain  may  be  the 
result  of  contre-coup,  the  brain  being  driven  across  its  bath  of  cerebro- 
spinal fluid  and  crashing  against  the  opposite  cranial  wall.  Thus  a 
fall  on  the  vertex  may  cause  but  slight  bruising  of  the  upper  surface 
of  the  brain,  while  the  lower  aspect  of  the  temporal  lobes  may  be  severely 
pulped. 

Anatomy.  The  effect  of  such  injuries  varies  very  much  ;  there  may 
be  only  slight  bruising  or  varying  degrees  of  laceration  up  to  complete 
pulping  of  the  cortex  and  underlying  brain.  This  is  always  associated 
with  haemorrhage,  leading,  if  severe,  to  cerebral  compression  or  focal  symp- 
toms, if  at  a  suitable  place.  Later  the  lacerated  part  becomes  red,  swollen, 
and  pulpy  (red  softening),  and  this  oedema  may  spread  to  a  large  pait 
of  the  brain,  causing  compression  (this  effect  is  due  to  compression  of  the 
veins  of  the  pia  mater  by  the  swollen  tissues)  ;  next,  deficiency  of  circula- 
tion leads  to  degeneration  of  the  affected  part,  which  becomes  yellow,  soft, 
and  pulpy  (yellow  softening).  If  the  area  is  small  recovery  may  follow, 
but  if  large  death  is  likely  to  result.  When  healed  a  tough  scar  results  which 
may  anchor  the  brain  to  the  meninges,  causing  headaches  or  fits,  or  cysts 
may  form  containing  haematoidin  resembling  those  already  noted  in  the 
arachnoid. 

Signs.  Minor  cases  present  the  picture  of  concussion,  but  with  slow 
return  of  consciousness  ;  cerebral  irritability,  impairment  of  memory,  and 
attention,  and  alteration  of  temper  make  it  fairly  certain  that  laceration  of 
macroscopic  nature  has  occurred.  In  more  severe  instances  the  symptoms 
are  those  of  the  associated  subdural  haemorrhage,  the  patient  passing  into 
coma  rapidly  or  after  an  interval  with  preliminary  fits  and  paralyses.  In 
very  severe  examples  there  will  be  convulsions,  soon  followed  by  coma 
and  death. 

The  focal  effects  from  injury  of  cortical  centres  have  already  been 
mentioned.     The  more  important  points  may  be  again  noted. 

(1)  The  Rolandic  Motor  Area.  Lesions  of  this  region  occasion  fits  of 
the  opposite  side  of  the  body,  starting  in  the  appropriate  group  of  muscles 
and  followed  by  paralysis,  the  convulsions  becoming  more  widespread  and 
the  paralysis  greater  and  more  marked  as  the  effused  blood  ploughs  up 
neighbouring  areas. 

Where  the  lesion  is  in  the  corona  radiata  there  will  be  spreading  paralysis 
of  the  opposite  side  without  fits,  and  if  the  lesion  is  in  the  internal  capsule 
the  march  of  paralysis  will  be  still  more  rapid  and  greater  at  the  onset 
owing  to  the  gathering-up  of  the  motor-fibres  in  one  compact  bundle. 

(2)  The  Occipital  Lobe.  Injuries  in  this  situation  cause  temporary  loss 
of  the  opposite  half-field  of  vision  (hemianopia)  ;  if  the  defect  does  not  pass 
off  the  lesion  is  probably  about  the  angular  gyrus. 

(3)  Where  there  is  laceration  of  the  corpus  striatum  and  haemorrhage 
into  the  lateral  ventricles  coma  comes  on  rapidly  and  hyperpyrexia  is 
common. 

(4)  Cerebellar  ataxy  may  result  from  laceration  of  this  organ. 


A  TEXTBOOK  OF  SURGERY 

Lacerations  of  the  lower  part  of  the  brain  are  usually  fatal  but  may 
1  ad  to  interesting  signs. 

Injury  to  the  erus  cerebri  will  cause  paralysis  of  the  oculomotor  nerve 
on  the  same  side  and  hemiplegia  <>n  the  other  side  of  the  body. 

Unilateral  injury  of  the  pons  causes  "crossed  paralysis"  from  injury 
of  the  pyramids  above  the  decussation  and  injury  of  the  nuclei  of 
origin  of  the  fifth,  sixth,  and  seventh  nerves,  as  well  as  contraction 
of  the  pupils. 

From  injuries  to  the  medulla,  in  addition  to  alterations  in  respiratory 
rhythm,  glycosuria  may  be  noted. 

After-results.  In  addition  to  the  various  mental  and  physical  defects 
described  under  Concussion  and  Cerebral  Irritation  (which  are  due  to 
laceration  of  the  brain),  cerebral  abscess  may  result  from  infection  of  the 
softening  area  of  brain  ;  this  is  discussed  under  Intracranial  Inflammation. 

Allusion  has  also  been  made  to  the  effects  of  cicatrices  and  "  anchoring  " 
of  the  brain. 

Treatment.  In  the  slighter  cases  treatment  is  as  for  concussion,  with 
more  prolonged  rest,  and  sedatives  and  purgatives  if  irritability  be  marked. 

Where  there  are  signs  of  compression  or  focal  symptoms  operation  is 
indicated  on  the  lines  laid  down  from  intracranial  ha?morrhage. 

Penetrating  Wounds  of  the  Brain  ;  Foreign  Bodies  in  the  Brain. 
Penetrating  wounds  of  the  brain  are  naturally  associated  with  depressed 
compound  fractures,  whether  these  are  caused  by  falls,  blows  with  sharp  or 
blunt  weapons,  or  bullet  injuries.  The  site  of  penetration  may  be  the  vertex, 
base,  or  any  intervening  point. 

In  many  of  these  cases  the  effects  are  much  less  severe  than  might  be 
expected,  partly  because  the  skull  is  opened  and  relief  is  thus  afforded  to 
increase  of  intracranial  tension  and  also  because  the  violence  is  largely 
expended  in  shattering  the  skull,  and  concussion  of  the  brain  is  confined  to 
the  part  actually  injured  and  does  not  spread  to  the  vital  centres  in  the 
medulla.  The  conditions  likely  to  follow  intracranial  bleeding  and  lacera- 
tion of  the  brain  will  be  minimized  owing  to  escape  of  blood  from  the  opening 
if  large,  and  from  the  safety-valve  afforded  to  oedematous  expansion  in  the 
same  way.  The  main  danger,  and  a  very  urgent  one,  is  the  infection  of 
brain  and  meninges  via  the  open  wound,  leading  to  spreading  meningitis  and 
encephalitis,  with  fatal  result. 

Signs.  The  diagnosis  rests  on  finding  a  wound  leading  through  the 
cranium  and  dura  into  the  brain,  and  the  discovery  of  such  a  condition 
demands  the  greatest  care  in  dealing  with  wounds  of  the  cranium,  especially 
those  in  the  roof  of  the  mouth,  orbital,  temporal,  and  occipital  regions. 
Such  wounds,  made  by  sharp  objects  such  as  sticks  or  umbrellas,  may 
extend  much  more  deeply  than  one  would  imagine.  A  careful  exploration 
oi  Midi  wounds,  after  preliminary  cleansing  with  finger  and  probe,  will  help 
to  show  the  extent  of  the  injury,  but  the  fact  that  the  six-inch  end  of  an 
umbrella  has  been  left  in  the  base  of  the  skull  and  impinging  on  the  medulla, 
from  a  wound  in  the  cheek,  gives  an  idea  of  the  difficulty  of  determining  the 


PENETRATING  WOUNDS  OF  THE  BRAIN  599 

extent   of  apparently  trifling   wounds.     In   other  cases   the   condition   is 
obvious,  the  brain  protruding  from  the  depressed  fracture. 

Early  recognition  of  the  condition  is  of  the  utmost  importance,  as  only 
so  can  the  part  be  rendered  relatively  aseptic  and  pressure  removed  from 
the  oedematous  brain  by  removing  fragments  of  skull,  foreign  bodies,  &c. 

In  addition  to  the  external  wound  there  may  be  evidences  of  concussion, 
compression  or  focal  signs,  as  in  non-penetrating  injuries,  the  latter  of  which 
may  be  useful  in  assisting  to  locate  foreign  bodies. 

Foreign  Bodies.  These  may  be  sharp,  spiky  objects  broken  off,  in  which 
case  there  will  be  little  difficulty  in  locating  them,  as  most  likely  one  end 
will  project  from  the  surface  or  not  be  far  out  of  view  The  point  of  a  knife, 
however,  or  similar  object  may  easily  escape  notice. 

Bullets.  In  these  cases  the  location  may  be  difficult.  In  the  first  place, 
the  surgeon  should  note  whether  there  is  not  also  an  aperture  of  exit,  which 
will  save  much  waste  of  time  if  the  bullet  has  passed  right  through.  Also 
if,  having  penetrated  the  cranium,  whether  it  has  also  pierced  the  dura  or 
run  along  between  the  latter  and  the  cranium  or  split  into  two  or  more 
pieces. 

For  accurate  location  of  bullets  X-rays  are  essential,  either  by  taking 
two  negatives  at  right  angles  to  each  other  or  from  slightly  different  points 
and  combining  them  stereoscopically  ;  this  will  show  the  position  very 
accurately,  and  this  may  be  marked  on  the  nearest  point  of  the  skull  and 
the  depth  noted. 

Treatment.  When  the  injury  is  in  some  inaccessible  spot,  as  through 
the  roof  of  the  mouth,  there  is  little  to  be  done  except  to  remove  loose 
fragments  and  any  foreign  body  that  can  be  reached  and  swab  out  the 
wound  with  1  in  20  carbolic,  administering  urotropin  to  render  the  parts  as 
aseptic  as  possible,  but  the  prognosis  is  poor.  Where  the  injury  is  accessible 
the  skull  should  be  freely  opened,  as  in  depressed  compound  fractures,  and 
loose  fragments  of  bone,  foreign  bodies,  pulped  brain  removed,  the  part 
cleansed  and  sutured  with  drainage  for  twenty-four  hours  :  if  it  is  certain 
that  a  foreign  body  is  in  the  brain,  examination  may  be  made  with  sterile 
instrument  or  ringer,  but  if  possible  radiographs  should  be  taken  first.  If 
signs  of  compression  or  sepsis  appear  the  wound  must  be  reopened  and 
drained,  but  there  is  little  hope  of  success. 

Bullets  in  the  Brain.     On  the  whole  it  is  wisest  in  most  instances  to  make 
at  least  one  determined  attempt  to  extract  a  bullet  impacted  in  the  brain. 

In  all  cases  the  wound  of  entry  should  be  opened,  as  in  other  depressed 
compound  fractures,  in  a  free  manner  (making  at  least  a  2-inch  aperture 
in  the  skull),  and  dirt,  fragments,  oozing  brain,  cleared  away  ;  the 
dura  and  subdural  space  should  be  cleansed  with  carbolic  1  in  20,  and 
then  if  the  radiograph  shows  the  bullet  not  far  from  the  point  of  entry 
a  probe  of  large  calibre  should  be  inserted  into  the  sinus  in  the  brain 
and  the  bullet  will  be  recognized  by  its  greater  resistance,  when  it  may 
be  extracted  with  forceps.  If  nothing  is  found  the  wound  should  be  closed 
with  drainage  for  twenty-four  hours,  and  it  will  be  then  better  to  wait  till 


600  A;  TEXTBOOK  OF  SCRGERY 

the  wound  is  healed  and  the  patient  is  in  better  condition  for  what  may  be 
a  prolonged  and  difficult  operation.  When  the  patient  has  recovered, 
fresh  estimation  of  the  position  of  the  bullet  should  be  made  with  radio- 
graphs, and  if  it  be  in  an  accessible  position,  i.e.  away  from  the  basal  ganglia, 
or  if  causing  symptoms,  a  determined  effort  should  be  made  to  extract 
it— not  necessarily  through  the  old  wound  but  through  the  most  acces- 
sible spot,  which  may  be  the  opposite  part  of  the  skull.  Whether  ;i 
bullet  or  other  body  is  causing  trouble  or  not  at  the  time,  it  will  be 
best  removed  from  the  brain.  Wharton  found  that  in  cases  where  the 
foreign  body  was  removed  70  per  cent,  recovered,  while  if  it  were  left 
only  fifty  lived. 

Moreover,  cases  which  recover  temporarily,  if  the  foreign  body  is 
left,  generally  have  deficient  cerebral  powers,  vertigo,  weakness  and  loss  of 
sight  or  hearing,  mental  deterioration,  etc.,  while  there  is  always  the  chance 
of  a  cerebral  abscess  lighting  up  around  a  foreign  body  even  years 
afterwards. 

Intracranial  Inflammation.  In  this  section  are  included  inflam- 
mations of  the  meninges  and  brain,  both  simple  and  suppurative,  as  well  as 
thrombosis  of  the  venous  sinuses.  Inflammations  in  this  region  are  usually 
infective  in  origin,  though  simple  varieties  due  to  repeated  injury  or  diffuse 
subdural  haemorrhage  also  occur.  The  organisms  causing  infections  of 
surgical  importance  are  mostly  pyogenic,  including  streptococci,  staphylo- 
cocci, pneumococci,  less  often  the  colon  bacillus  and  the  bacillus  pyocyaneus, 
while  in  epidemic  cerebro-spinal  meningitis  the  diplococcus  intracellularis 
is  responsible.  The  spirochsete  of  syphilis  and  the  tubercle  bacillus  cause 
many  lesions,  and  though  most  of  these  conditions  come  into  the  hands  of 
physicians,  still  a  number  demand  surgical  interference.  Pyogenic  infec- 
tions reach  the  inside  of  the  cranium  by  three  main  routes  : 

(1)  As  the  result  of  local  injury,  commonly  from  depressed  compound 
fractures,  especially  of  the  punctured  variety,  and  above  all  if  the  dura  has 
been  penetrated,  less  often  by  spread  from  an  infected  scalp-wound  through 
the  emissary  veins  of  the  cranial  wall. 

(2)  The  most  common  cause  is  by  spread  of  disease  from  neighbouring 
parts,  above  all  from  the  middle  ear  and  mastoid,  which  may  be  regarded 
as  the  Jons  el  origo  of  most  pyogenic  intracranial  infections.  Cellulitis  and 
erysipelas  of  the  face  and  scalp  will  also  account  for  a  few  cases. 

(3)  Embolic  or  pyaemic  infection  causes  infection  of  the  brain  in  a  few 
instances,  and  this  results  more  commonly  from  bronchiectatic  cavities 
"f  the  lung  than  any  other  focus. 

Since  by  far  the  greater  number  of  cases  of  acute  infection  of  the  brain 
and  meninges  of  surgical  importance  are  secondary  to  infection  of  the 
middle  ear  and  mastoid,  it  seems  best  to  consider' the  surgery  of  the  ear 
before  going  further  into  the  matter  of  intracranial  infections.  From  the 
standpoint  of  the  general  surgeon  the  ear  may  be  regarded  as  a  some- 
what dangerous  appendage  of  the  brain,  and,  apart  from  middle-ear  disease, 
intracranial  infections  form  a  very  minor  part  of  surgery  (p.  620). 


ANATOMY  OF  THE  EAR  601 


SURGERY  OF  THE  EAR 


Anatomy.  From  the  concha  the  cartilaginous  part  of  the  auditory 
meatus  leads  to  the  osseous  portion,  which  is  slightly  narrower.  Imme- 
diately behind  the  cartilaginous  meatus  the  posterior  auricular  artery 
courses  vertically  upwards.  The  meatus  terminates  at  the  tympanic 
membrane  or  drum,  which  is  stretched  tightly  across  the  opening  into  the 
middle-ear  except  at  its  upper  part,  where  it  is  slack  (membrana  flaccida 
or  Shrapnel's  membrane).  The  membrana  is  set  obliquely  across  the 
meatus,  so  that  the  anterior  inferior  edge  is  nearest  the  middle  line  and 
forms  an  angle  of  about  fifty  degrees  with  the  floor  of  the  meatus. 

The  central  part  of  the  membrane  or  "  umbo  "  is  drawn  inwards  by  the 
attached  handle  of  the  malleus  so  that  the  membrane  is  slightly  concave. 

The  middle-ear,  or  tympanum,  is  a  flat  cavity  in  the  temporal  bone 
intervening  between  the  tympanic  membrane  and  the  outer  wall  of  the 
internal  ear.  This  cavity  is  narrow  from  side  to  side  and  extends  some 
way  above  the  top  of  the  membrane  as  the  epitympanic  space  or  attic,  into 
the  back  of  which  leads  the  adit  or  opening  from  the  mastoid  antrum,  while 
in  front  the  Eustachian  tube  leads  into  the  naso-pharynx. 

The  outer  wall  of  the  middle  ear  is  formed  chiefly  of  the  membrana 
tvmpani,  on  which  lies  the  handle  of  the  malleus  crossed  by  the  chorda - 
tympani.  The  inner  wall  of  the  middle  ear  is  in  front  bulged  outward  by 
the  large  first  turn  of  the  cochlea,  while  behind  this  are,  above,  the  fenestra 
ovalis  receiving  the  foot  of  the  stapes  and,  below,  the  fenestra  rotunda, 
closed  with  membrane  and  leading  into  the  internal  ear.  Behind  these 
again  is  the  stapedius  muscle  coming  out  of  the  pyramid,  and  encircling  the 
fenestra?  and  pyramid  above  and  behind  is  the  bulge  caused  by  the  aque- 
duct of  Fallopius  containing  the  facial  nerve,  which  lies  just  at  the  junction 
of  the  attic  with  the  main  part  of  the  middle  ear.  Bulging  into  the  attic 
behind  the  Fallopian  aqueduct  is  the  prominence  caused  by  the  ampulla 
where  the  superior  and  external  semicircular  canals  join.  Anteriorly  the 
middle  ear  narrows  to  a  bony  tube  divided  in  two  by  the  cochleariform 
process,  above  which  is  the  tensor-tympani  muscle,  whose  tendon  is  attached 
to  the  handle  of  the  malleus  and  draws  the  drum  inwards,  while  the  lower 
part  is  the  commencement  of  the  Eustachian  tube. 

Across  the  middle  ear  stretches  the  chain  of  ossicles  :  the  malleus  against 
the  membrana  tympani,  the  stapes  fitting  into  the  fenestra  ovalis,  and  the 
incus  forming  a  connecting  link  between  the  other  two.  The  head  of  the 
malleus  and  the  body  of  the  incus  lie  above  the  membrane  in  the  attic. 
The  middle-ear  is  lined  with  mucous  membrane.  The  mastoid  antrum, 
which  is  present  at  birth,  is  a  cavity  behind  and  above  the  middle-ear  con- 
nected to  the  attic  of  the  latter  by  a  short  channel,  the  adit.  As  the  mastoid 
process  develops,  the  cancellous  bone  around  the  antrum  becomes  hollowed 
into  air-cells  on  the  posterior  and  inferior  aspects.  These  air-cells  vary 
greatly  in  extent ;  in  some  instances  the  mastoid  consists  mostly  of  air- 
cells,  in  others  there  is  still  much  cancellous  bone  left ;   while  as  the  result 


602 


A  TEXTBOOK  OF  SURGERY 


of  prolonged  inflammation  the  whole  process  may  be  much  thickened, 
sclerosed,  and  eburnated.  Air-cells  may  also  extend  into  the  squamous 
portion  of  the  bone  as  well.     The  Eustachian  tube  is  the  external  opening 

of  the  middle  ear  into  the  naso-pharynx,  through  which  the  pressure  of 
air  inside  the  middle  ear  is  regulated  so  as  to  be  equal  on  either  side  of 
the  membrana  tympani.  This  tube  represents  the  relic  of  the  inner  part 
of  the  first  gill-cleft  of  the  embryo  (the  external  meatus  being  the  outer 
part),  and  consists  of  a  posterior  osseous  portion  in  the  anterior  part  of  the 


Fig.  236.  Photograph  of  a  skull  in  which  the  mastoid  antrum  and  middle  ear  have 
been  made  into  one  cavity  (as  in  the  radical  operation)  to  show  the  neighbouring 
relations.  I,  Place  to  explore  for  cerebellar  abscess.  II,  To  enlarge  the  opening 
into  the  mastoid  upward  in  exploring  the  tempore- sphenoidal  lobe.  Ill,  Position 
of  the  carotid  artery.  IV,  Outline  of  the  lateral  sinus,  a,  External  semicircular 
canal,  b,  Canal  of  facial  nerve  laid  open,  c,  Fenestra  ovalis.  d,  Fenestra 
rotunda,  e,  Cochlea.  The  narrow  aditus  leading  from  the  antrum  to  middle  ear 
is  well  seen,  the  straight  dotted  line  above  the  antrum  shows  the  position  of  the  floor 

of  the  middle  fossa. 

petrous  bone  and  an  anterior  portion  of  cartilage  one  inch  in  length,  which 
opens  into  the  lateral  wall  of  the  naso-pharynx,  just  behind  the  posterior 
end  of  the  inferior  turbinate  and  in  front  of  the  depression  known  as  the 
fossa  of  Rosenmuller.  The  cartilaginous  portion  of  the  Eustachian  tube  is 
normally  closed  by  apposition  of  its  lateral  walls,  but  is  opened  in  the  action 
of  swallowing  or  in  the  formation  of  certain  sounds,  such  as  "  buck." 

The  direction  of  the  tube  is  downwards  and  inwards,  being  inclined  to 
the  horizontal  at  about  40°.  In  children  the  inclination  is  much  less,  the 
tube  being  nearly  horizontal,  which  may  in  part  account  for  the  greater 
proclivity  of  children  to  infections  of  the  middle  ear  spreading  from  the  naso- 
pharynx. 

Cranial  and  Intracranial  Relations  of  the  Middle  Ear.  The  inner 
wall  of  the  tympanum  is  related  to  the  internal  ear  and  facial  nerve. 
Above,  the  middle  ear,  Eustachian  tube  and  antrum  are  covered  by  a  thin 


EXAMINATION  OF  THE  EAR  603 

plate  of  bone,  the  tegmen  tympaui,  which  separates  them  from  the  middle 
fossa  of  the  skull  (temporo-sphenoidal  lobe).  The  outer  border  of  the 
tegmen  articulates  by  the  petrosquamous  suture  with  the  squamous  portion, 
and  this  remains  unossified  for  some  years  after  birth,  thus  allowing  easy 
passage  of  inflammation  from  the  middle  ear  and  mastoid  to  the  middle 
fossa  of  the  skull.  The  floor  of  the  tympanum  is  related  to  the  jugular 
fossa  and  the  carotid  canal,  both  of  which,  especially  the  former,  are  in 
danger  of  inspreading  infection  from  the  middle  ear.  In  front  the  external 
meatus  and  tympanum  are  in  relation  to  the  glenoid  fossa  and  parotid 
gland.  The  mastoid  antrum  is  related  behind  to  the  posterior  fossa  (cere- 
bellum) and  lateral  sinus,  below  and  to  the  outside  to  the  mastoid  cells.  On 
the  surface  the  position  of  the  mastoid  is  marked  by  a  depression  of  triangular 
shape  immediately  behind  and  above  the  bony  external  meatus. 

Examination  of  the  Ear.  The  ear  is  investigated  by  inspection  and 
palpation  of  the  external  auditory  meatus  and  tympanic  membrane,  the 
mastoid,  and  structures  beneath  the  sternomastoid  muscle  (lymph-nodes 
and  jugular  vein)  ;  by  studying  the  permeability  of  the  Eustachian  tube 
and  the  condition  of  the  naso-pharynx,  and  by  testing  the  condition  of 
hearing. 

External  Examination.  Various  changes  in  the  auricle  may  be  noted, 
or  tenderness,  redness,  swelling,  fluctuation,  or  a  fistula  over  the  mastoid. 

Swelling  and  oedema  may  be  noted  below  the  mastoid,  under  the  upper 
part  of  the  sternomastoid  muscle,  denoting  enlargement  of  glands,  or 
perforation  of  the  mastoid  on  its  deep  surface  from  suppuration  (v.  Bezold's 
mastoiditis)  or  thrombosis  of  the  jugular  vein. 

Aural  Speculum.  To  examine  the  external  meatus  and  membrane  a 
hollow,  conical  speculum  is  inserted  into  the  meatus,  light  being  reflected 
by  a  concave  mirror  (preferably  of  short  focus)  through  a  perforation  in 
the  centre  of  which,  the  surgeon  makes  his  observations. 

Before  examining,  the  meatus  should  be  thoroughly  cleaned  by  removal 
of  pus,  cerumen,  debris,  &c,  by  gentle  syringing  after  instillation  of  hydrogen 
peroxide,  or,  if  there  is  much  inspissated  cerumen,  drops  containing  sodium 
bicarbonate  and  glycerin  should  be  instilled  for  two  days  beforehand  : 
after  syringing,  the  meatus  is  gently  dried  with  small  pieces  of  wool  held 
on  curved  aural  forceps,  and  this  must  be  thoroughly  done  if  an  accurate 
diagnosis  is  to  be  made. 

The  normal  drum  is  shining  and  semitranslucent,  permitting  a  view  of 
the  handle  of  the  malleus  and  its  short  process  through  its  substance  :  a 
cone  of  reflected  light  runs  forwards  from  the  central  umbo.  If  the  mem- 
brane is  atrophic  the  incus  may  be  seen  as  well,  behind  the  malleus. 

Atrophic  patches  from  healed  perforations,  or  perforations  either  healed 
and  clean-edged  or  recent  and  exuding  pus,  or  calcified  patches  denoting 
old-standing  inflammation,  may  be  noted.  Indrawing  of  the  membrane 
may  be  detected  by  noting  the  foreshortening  of  the  handle  of  the  malleus 
and  the  excessive  projection  of  its  short  process.  Perforations  may  be  so 
large  that  practically  no  membrane  is  left,  the  inner  wall  of  the  tympanum 


604 


A  TEXTBOOK  <>F  SURGERY 


being  seen  covered  with  granulations.  The  meatus  may  be  blocked  with 
polypi  or  these  may  protrude  through  perforations.  On  touching  with 
a  probe  a  soft,  mobile  polypus  can  be  readily  distinguished  from  a  hard. 
fixed  exostosis.  Furuncles  may  be  seen  as  tender  projections  from  the 
wall  of  the  meatus,  perhaps  exuding  pus.  and  the  thickening  of  the  meatal 
skin  and  desquamated  epithelium  from  chronic  inflammation  of  the  meatus 
(eczema)   should   be   noted.     With   the   pneumatic   speculum   (Siegle)   the 

mobility  of  the  drum  may  be  tested  ;  this 
instrument  is  also  useful  for  extracting  pus 
from  the  middle  ear  through  a  perforation. 
The  tympanic  membrane  may  be  red 
and  inflamed,  possibly  covered  with  vesicles 
(myringitis),  or  the  line  caused  by  the 
surface  of  a  collection  of  serum  inside  the 
middle  ear  may  be  noted  :  if  there  is  acute 
suppuration  in  the  middle  ear  the  mem- 
brane will  be  red,  cedematous,  and  bulging 
outwards,  the  glistening  surface  and  the 
outline  of  the  malleus  entirely  obscured. 

Investigation  of  the  Eustachian  Tube. 
This  may  be  done  by  Politzer's  method  or 
with  the  Eustachian  catheter ;  Valsalva's 
experiment  is  not  advisable  owing  to  the 
congestion  of  the  middle  ear  resulting. 

The  diagnostic  tube  passing  from  the 
ear  of  the  patient  to  that  of  the  surgeon 
will  give  information,  whichever  method 
is  practised. 

(a)  Politzer's  Method.  Air  is  sharply 
blown  into  one  nostril  with  a  rubber  bag 
and  tube,  the  other  nostril  being  held.  At 
the  moment  that  the  air  is  forced  into  the 
nose  the  patient  swallows  a  sip  of  water 
or  ejaculates  "  huck,"  which  opens  the 
The  result,  if  the  latter  be  patent,  is  that  air  rushes 
into  the  middle  ear  with  what  appears  to  the  patient  like  the  noise  of 
thunder,  but  to  the  surgeon  listening  at  the  diagnostic  tube  a  gentle  click  ; 
if  there  is  fluid  in  the  middle  ear  the  surgeon  hears  a  bubbling  sound,  if 
a  perforation  of  the  drum  he  notes  a  hiss  ;  if  the  Eustachian  tube  is 
blocked  there  will  be  a  still  silence. 

(b)  The  Eustachian  catheter  is  a  small,  suitably  curved  tube  of  metal 
or  vulcanite  which  is  introduced  into  the  pharyngeal  orifice  of  the  Eustachian 
tube,  and  when  air  is  blown  along  this  with  the  bag  the  surgeon  hears  similar- 
sounds  as  when  the  former  method  is  used. 

The  catheter  is  introduced  through  the  inferior  meatus  of  the  nose 
(after  spraying  with  10  per  cent,  cocain  solution),  being  passed  backwards 


Fig.  237.  A,  Diagram  of  the  mem- 
brana  tympani,  showing  the  handle 
of  the  malleus  to  the  left,  the  short 
process  only  just  visible :  behind  is  the 
short  process  of  the  incus  ;  the  black 
spot  behind  represents  a  perforation. 
B,  Section  through  the  skull,  middle 
ear  and  external  meatus.  Note  the 
membrane  is  gently  bulging  in  at  the 
umbo.  The  ossicles  are  are  omit  ted 
in  the  lower  section. 


Eustachian  tube. 


TESTS  OF  HEARING  605 

till  the  posterior  wall  of  the  pharynx  is  felt,  and  then  turned  inwards  through 
a  right  angle  and  drawn  back  till  the  curved  end  catches  on  the  posterior 
edge  of  the  nasal  septum  ;  it  is  then  rotated  through  180°  so  that  the 
point  is  outwards,  when  this  should  be  in  the  orifice  of  the  tube.  Some 
little  practice  is  needed  to  do  this  with  ease  and  decency,  particularly  if 
the  nose  is  blocked  with  enlarged  turbinates  or  deviations  of  the  septum. 
If  the  nostril  is  very  impervious  the  catheter  may  be  introduced  through 
the  other  nostril,  but  in  that  case  will  need  a  larger  curve  at  the  end. 

The  naso-pharynx  should  be  examined  by  posterior  rhinoscopy  (see 
Surgery  of  the  Nose)  or  by  passing  a  finger  behind  the  soft  palate,  to  detect 
the  presence  of  adenoid  vegetations,  hypertrophy  of  the  posterior  ends 
of  the  turbinates,  or  naso-pharyngeal  tumour. 

Tests  of  Heaking.  Normally  sounds  are  conducted  for  the  most  part 
by  vibrations  of  the  drum  and  ossicles  to  the  internal  ear  (air  conduction), 
and  much  less  by  vibrations  passing  through  the  bones  of  the  skull  (bone- 
conduction).  Alterations  in  the  relative  efficacy  of  these  paths  of  conduc- 
tion are  the  basis  of  Weber's  and  Rhine's  tests  for  ascertaining  defects  of 
the  middle  ear. 

(1)  Weber's  test  consists  in  placing  a  tuning-fork  of  300  to  400  vibra- 
tions per  second  on  the  top  of  the  head,  when  if  the  affection  of  the  ear  is 
in  the  external  or  middle  ear  (cerumen,  fluid  in  the  middle  ear,  indrawn 
membrane,  &c.)  the  sound  is  heard  most  plainly  in  the  affected  ear  (a  simple 
example  is  to  place  the  tuning-fork  on  the  head  and  stop  one  ear  with 
the  finger,  when  the  sound  will  be  heard  best  in  that  ear). 

Where  the  internal  ear  or  auditory  nerve  is  at  fault  the  sound  is  heard 
best  on  the  sound  side. 

(2)  Rinne's  Test.  Normally,  if  the  tuning-fork  is  held  on  the  mastoid 
till  the  sound  is  no  longer  heard  and  then  immediately  placed  opposite  the 
meatus,  it  will  be  heard  again  ;  but  if  the  middle  ear  is  affected  the  sound 
will  be  heard  much  longer  with  the  fork  over  the  mastoid — or,  in  other 
words,  "  bone  conduction  "  is  relatively  increased.  Where  the  trouble  is 
in  the  internal  ear  the  sound  w  11  be  heard  best  by  "  air  conduction." 

To  test  practical  function  of  the  ear,  phonated  and  whispered  speech 
is  tried  for  each  ear  alternately.  Whispering  should  be  heard  at  six 
yards. 

T inn dus  is  applied  to  subjective  noises  in  the  ear  of  various  sorts — 
humming,  rustling,  whistling,  ringing,  loud  explosions,  pulsations -and  may 
be  due  to  most  abnormal  conditions  of  external,  middle,  or  internal  ear 
(wax,  pus,  scarring  and  adhesions  of  the  drum,  inflammations  and  degenera- 
tions of  the  auditory  nerve  and  ganglia,  or  the  use  of  drugs,  e.g.  the  buzzing 
produced  by  quinine  or  salicylates,  and  is  well  known  in  arterio-sclerosis 
and  anaemia). 

Where  due  to  affections  of  the  external  or  middle  ear  the  treatment  is 
directed  to  the  underlying  condition  (wax,  pus,  &c),  but  if  due  to  involve- 
ment of  the  internal  ear  or  nerve  treatment  is  very  difficult,  as  the  constant 
irritation  of  what  seems  a  trifling  matter  has  a  very  depressing  effect  on 


•  in.;  A  TEXTBOOK  OF  SURGERY 

tin*  patient.     Bromides  and  hydrobroniie  arid  air  advised,  as  well  as  general 
attention  to  health  and  such  conditions  as  arteiio-sclerosis  or  anaemia. 

Auditory  vertigo,  or  giddiness,  may  accompany  many  affections  of  the 
ear.  The  term  is  chiefly  applied  to  Meniere's  symptom-complex  of  vertigo, 
tinnitus,  vomiting  (paroxysmal  and  recurring),  and  progressive  deafness 
without  loss  of  consciousness,  which  is  due  to  haemorrhages  into  the  laby- 
rinth and  is  to  be  distinguished  from  the  effects  of  cerumen  or  cerebellar 
disease. 

(1)  Affections  of  the  External  Ear.  (a)  Congenital  Defects.  The 
ear  may  be  entirely  absent,  but  a  more  common  condition  is  one  of  atresia 
of  the  meatus  and  shrinking  and  crumpling  of  the  external  ear.  It 
is  no  use  attempting  to  restore  the  meatus,  as  the  internal  ear  will  be  func- 
tionless  or  absent ;  but  if  very  unsightly  a  plastic  operation  may  be  done 
to  improve  the  shape  and  appearance  of  the  ear. 

(b)  Injuries.  Hcematoma  auris,  or  effusion  of  blood  between  the  carti- 
lage and  skin,  is  generally  the  mark  of  a  boxer  or  a  player  of  Rugby  football, 
but  may  be  due  to  other  violence  and  is  said  to  occur  spontaneously  in 
lunatics.  In  the  acute  stage  the  swelling  resembles  an  over-ripe  tomato 
and,  owing  to  slow  absorption  of  blood,  there  is  later  much  fibrous  thickening, 
distorting  the  shape  of  the  pinna  and  leaving  the  well-known  "  thick  ear." 

Treatment.  Where  there  is  a  large  haematoma,  as  much  deformity  will 
follow  if  this  is  left  to  become  absorbed  and  considerable  chance  of  suppura- 
tion and  necrosis  of  cartilage,  which  is  very  painful  and  tedious,  it  will  be 
best  to  evacuate  blood  and  clots  by  a  small  incision  and  firmly  bandage  so 
that  further  effusion  is  checked. 

Eczema  is  common  here  in  children,  possibly  a  sequel  to  otitis  media 
but  often  apart  from  this,  and  is  treated  with  soothing  lotions  and  ointments. 
The  condition  Raynaud's  disease,  in  wrhich  dry  gangrene  of  the  ear- 
tips  takes  place,  has  been  mentioned  (see  Gangrene,  p.  64). 

New  Growths.  Sebaceous  cysts  are  not  uncommon.  Epithelioma  occurs 
as  a  fungating  tumour,  usually  of  the  upper  part  of  the  pinna  in  middle- 
aged  persons.  This  should  be  freely  removed  with  the  mastoid  glands  or 
those  of  the  deep  cervical  chain  if  the  condition  is  of  long  standing. 

Rodent  ulcer  occurs,  especially  at  the  junction  of  the  ear  with  the  scalp 
at  the  upper  and  anterior  aspect.  X-rays  or  ionisation  with  zinc  will 
cure  for  many  years. 

(2)  Affections  of  the  Meatus,  (a)  Foreign  Bodies.  These  are  often 
placed  in  the  meatus,  and  are  likely  to  cause  inflammatory  ulceration  and 
suppuration  if  not  removed.  History  and  inspection  will  generally  reveal 
their  nature.  If  hard  and  not  likely  to  swell  by  absorbing  water  (beads, 
buttons),  they  may  usually  be  removed  by  syringing  out  the  meatus  with 
warm  water,  first  pulling  the  auricle  backwards  to  straighten  the  meatus.  Soft 
bodies  such  as  peas,  beans,  and  other  seeds  should  be  extracted  with  a  tiny 
sharp  hook,  the  point  of  which  is  made  to  engage  in  the  side  of  the  foreign 
body  (the  oculist's  cystotome  serves  admirably  for  this  purpose)  :  care  is 
needed  not  to  push  the  body  further  in,  or  to  injure  the  drum.     In  children 


CERUMEN.    FURUNCLES  607 

an  ansesthetic  is  advisable.  Finally,  if  these  measures  fail,  or  where  there 
are  already  inflammation  and  suppuration  around  the  body,  the  ear  should 
be  turned  forward  by  an  incision  as  for  mastoidectomy,  bony  meatus  opened 
with  the  chisel,  and  the  object  removed. 

(b)  Impacted  Cerumen.  The  commonest  cause  of  deafness  is  impaction 
of  inspissated  wax  in  the  meatus.  This  is  removed  by  syringing,  first 
softening  the  wax  by  instillation  of  hydrogen  peroxide  or,  better,  using 
drops  of  sodium  bicarbonate  gr.  10,  glycerin  1  dr.,  to  the  ounce  of  water. 
If  this  fluid  is  instilled  into  the  ear  night  and  morning  for  two  days  removal 
with  the  syringe  is  made  easy.  After  removal  of  wax  the  membrane  should 
be  inspected  and  tests  of  hearing  repeated,  Politzerizing  the  Eustachian  tube 
if  any  deafness  remains. 

(c)  Inflammations.  (1)  Eczema  of  a  chronic  nature  is  known  by  the 
redness  and  tenderness  of  the  skin  and  desquamation  of  epithelium,  the 
meatus  appearing  swollen,  whitish,  and  sodden. 

Treatment.  The  debris  is  syringed  out  with  alkaline  lotion  and  calamine 
lotion  or  lotion  of  the  glycerin  of  subacetate  of  lead  instilled,  and  later,  as 
the  inflammation  quiets  down,  ammoniated  mercury  ointment  may  be 
used. 

(2)  Furuncles  or  Boils.  These  are  found  in  the  cartilaginous  part  of  the 
meatus  from  staphylococcal  infection  of  hair-follicles,  and  may  be  consecu- 
tive to  otorrhoea,  though  more  often  primary,  and  often  recur  in  series. 

Signs.  There  is  great  pain  and  tenderness  over  the  meatus  and  oedema 
around  both  in  front  and  possibly  behind  over  the  mastoid,  the  pre- 
auricular glands  are  enlarged.  This  affection  is  often  mistaken  for  mas- 
toiditis unless  care  be  taken.  The  swelling  in  the  meatus,  possibly  dis- 
charging a  little  pus,  the  usual  absence  of  any  history  of  otitis  media,  and 
the  tenderness  over  the  front  of  the  meatus  (in  front  of  the  tragus)  and  not 
over  the  mastoid,  even  though  the  latter  be  cedematous,  will  generally  decide 
the  question. 

Treatment.  In  the  early  stages  pain  is  relieved  by  instilling  warm 
glycerin  of  carbolic  acid  into  the  ear,  but  when  the  furuncle  is  manifest 
it  should  be  incised  (under  general  anaesthesia)  and  the  slough  scraped  out, 
the  ear  being  washed  out  frequently  with  dilute  antiseptic  lotion.  Where 
the  condition  is  recurrent  vaccine  therapy  may  be  instituted. 

(3)  Sinuses  in  the  meatus  should  be  carefully  investigated,  as  they 
may  be  simply  due  to  furuncles,  but  may,  especially  if  in  the  posterior  and 
upper  part  of  the  meatus,  be  due  to  otitis  media,  in  which  case  the  probe 
will  reveal  bare  bone.    Treatment  is  according  to  the  underlying  condition. 

(d)  Tumours.  (1)  Exostoses  are  of  the  ivory  variety,  and  only  need 
removal  if  blocking  the  meatus  considerably  ;  they  are  known  by  their 
hardness  and  fixity  when  probed.     In  removal  care  of  the  drum  is  needed. 

(2)  Epithelioma  occurs  as  a  warty  growth  which  breaks  down  and 
fungates,  causing  a  blood-stained  discharge,  being  usually  found  in  middle- 
aged  or  old  persons.  The  growth  invades  the  middle  ear  and  has  to  be 
distinguished  from  chronic  suppurative  otitis  media,  which  may  not  be  an 


608  A  TEXTBOOK  OF  SURGERY 

easy  matter  unless  sections  are  examined.  Hence  where  there  is  much  fungus 
granulation  in  middle-aged  persons  and  the  condition  is  of  moderately 
recent  origin,  the  granulations  should  be  examined  microscopically. 

Treatment.  The  growth  should  be  removed  widely,  including  the  meatus 
and  middle  ear  in  most  instances,  while  the  cervical  and  mastoid  glands 
should  be  cleared  out. 

(2)  Affections  of  the  Middle  Ear.  (a)  Injuries.  Rupture  of  the 
tympanic  membrane  may  result  from  ill-advised  attempts  at  removing 
foreign  bodies  by  the  introduction  of  foreign  bodies  or  from  strong  vibra- 
tions of  the  air,  as  the  firing  of  heavy  guns  ;  the  injury  may  be  confined  to 
the  drum  or  may  be  combined  with  fracture  of  the  base  of  the  skull  or 
other  injury  to  the  middle  ear. 

Signs.  Deafness,  slight  bleeding  from  the  ear,  and  on  inspection  the 
rent  in  the  drum  will  be  seen,  and  if  the  Eustachian  tube  be  inflated  air  may 
be  heard,  with  the  diagnostic  tube,  to  whistle  through  the  hole.  If  uncom- 
plicated by  such  dangerous  conditions  as  fracture  of  the  base  of  the  skull, 
healing  is  satisfactory  in  most  cases  with  restoration  of  hearing. 

Treatment.  The  meatus  should  be  syringed  .  out  gently  with  weak 
carbolic  lotion  and  a  light  pack  of  sterile  gauze  placed  inside.  Later, 
Politzerization  may  be  needed. 

(b)  Inflammations  oj  the  Middle  Ear.  These  are  nearly  always  of  infec- 
tive origin,  usually  secondary  to  disease  of  the  naso-pharynx  via  the  Eusta- 
chian tube  or  set  up  by  blocking  of  the  tube  from  inflammations  about 
its  naso-pharyngeal  orifice.  Infection  through  the  external  meatus  seldom 
takes  place  after  rupture  of  the  membrane,  but  may  be  lighted  up  from 
infection  (by  bathing,  &c.)  through  perforations  of  old  standing,  due  origi- 
nally to  disease  spreading  from  the  naso-pharynx.  Blood-borne  infection 
is  uncommon  except  with  tubercle  bacilli  in  young  subjects.  The  path  of 
infection  along  the  Eustachian  tube  being  constantly  open,  re-infection 
is  always  liable  to  occur  ;  hence  the  importance,  in  the  treatment  of  inflam- 
mations of  the  middle  ear,  of  dealing  with  abnormal  conditions  of  the  naso- 
pharynx (e.g.  adenoids)  as  well  as  treating  the  local  affection.  The  organisms 
responsible  for  these  infections  are  streptococci,  especially  in  the  destructive 
inflammations  following  scarlet  fever  ;  the  pneumococcus  is  common  in 
adults  and  children,  while  staphylococcal  infection  is  uncommon.  In  the 
chronic  suppurative  lesions  a  large  part  of  the  bacterial  flora  is  adventitious, 
including  bacilli  of  the  colon  and  proteus  groups  and  the  true  and  false 
diphtheria  bacilli. 

For  practical  purposes  inflammation  of  the  middle  ear  may  be  divided 
into  : 

(1)  Simple  non-suppurative  affections,  including  Eustachian  catarrh. 

(2)  Acute  inflammation  and  suppuration. 

(3)  Chronic  suppuration. 

(4)  Otosclerosis. 

(1)  Simple  Otitis  Media  and  Eustachian  Catarrh.  A  congestive  inflam- 
mation takes  place  about  the  pharyngeal  orifice  of  the  Eustachian  tube, 


E  r  ST  AC  HIAN  CATARRH 


G09 


secondary  to  infections  of  the  naso-pharynx,  very  often  associated  with 
adenoids.  As  a  result  of  this  the  tube  becomes  blocked  and  the  air  in  the 
middle  ear  is  absorbed  by  the  blood  in  the  lining  mucosa,  thus  lowering 
the  pressure  inside  the  middle  ear,  and  the  drum  is  driven  inward  by  the 
greater  pressure  outside.  When  this  condition  remains  long  continued 
the  drum  membrane  becomes  atrophic,  or  fluid  may  collect  inside  the  middle 
ear,  either  as  an  oedematous  exudate 
or  a  mild  catarrhal  inflammation. 
The  resistance  of  the  middle  ear  is 
lowered  by  this  condition  and  it  is 
more  readily  infected  with  virulent 
organisms,  leading  to  acute  suppu- 
rative otitis  media.  The  results  to 
the  patient  are  deafness  (of  the 
middle-ear  type)  and  tinnitus. 

Signs.  On  examiation  the  mem- 
brane is  seen  to  be  retracted  and 
in  old-standing  cases  atrophic  and 
transparent,  while  the  upper  surface 
of  a  collection  of  fluid  may  cause 
the  appearance  of  a  horizontal  line 
across  the  membrane.  On  inflating 
the  Eustachian  tube  a  bubbling 
sound  is  heard  with  the  diagnostic 
tube  and  the  deafness  will  be  im- 
proved. 

Treatment.  Any  abnormality  of 
the  naso-pharynx  should  be  treated, 
adenoids  removed,  nasal  obstruction 
obviated  (e.g.  resection  of  a  deviated 
septum).  After  this  has  been  done 
the  middle  ear  is  inflated  via  the 
Eustachian  tube,  for  choice  by  Polit- 
zer's  method,  and  in  early  cases  re- 
covery will  be  good.  Should  the  membrane  be  atrophic  or  adherent  to  the 
inner  wall  of  the  middle  ear  improvement  will  be  slight ;  hence  the  import- 
ance of  early  treatment  and  removal  of  adenoids,  &c,  in  deaf  children. 

(2)  Acute  Otitis  Media.  This  may  be  regarded  as  an  exaggerated  con- 
dition of  Eustachian  catarrh,  in  which  not  only  is  the  tube  blocked  by 
inflammatory  congestion  but  the  latter  process  has  spread  to  the  middle 
ear,  and  if  caused  by  virulent  organisms  may  assume  severe  proportions, 
destroying  the  tympanic  membrane,  infecting  surrounding  bone,  pene- 
trating the  cranial  fossse,  &c. 

The  violence  of  the  inflammation  varies  from  a  moderate  catarrh  of  the 
middle  ear  with  serous  effusion  to  violent  suppuration  causing  great  destruc- 
tion of  the  middle  ear  and  its  surroundings. 

i  39 


Fig.  238.  A,  To  show  the  effect  of  indrawing 
of  the  membrana  tympani.  The  handle  of  the 
malleus  appears  .short,  but  its  short  process 
appears  more  distinct.  B,  Section  through 
the  skull  and  middle  ear,  showing  connexion 
to  middle  and  posterior  fossa,  a,  Temporo- 
sphenoidal  lobe  of  brain,  b.  Opening  of  aditus. 
c,  Facial  nerve  in  aqueduct  of  Fallopius. 
'/.  First  turn  of  cochlea,  e,  Auditory  and 
facial  nerves  in  internal  meatus. — Note  in 
this  example  the  membrane  is  considerably 
bulged  inwards.  (Compare  Fig.  237. 


610  A  TEXTBOOK  OF  SURGERY 

Thf  importance  of  Btreptococci  and  pneumococci  has  been  mentioned. 
Acute  otitis  media  is  common  in  children  suffering  from  scarlet  fever  or 
measles,  is  less  often  found  in  cases  of  the  other  exanthemata,  as  enteric, 
and  in  adults  oft  on  arises  as  a  complication  of  influenza. 

Anatomy.  In  the  early  stages  there  is  congestion  of  the  lining  mucosa 
of  the  middle  ear  and  mastoid  antrum,  with  secretion  of  serous  fluid  or  pus 
according  to  the  virulence  of  infection.  This  may  subside  and  the  ear  be 
restored  to  a  normal  condition.  Should,  however,  infection  spread  to  the 
underlying  structures,  the  drum,  being  the  thinnest,  is  most  easily  affected 
and  gives  way  from  inflammatory  softening  of  its  substance  and  the  increase 
of  intra-tympanic  tension.  Such  a  perforation  of  the  membrane  generally 
saves  the  situation,  preventing  deeper  infection  of  the  osseous  walls. 
Should  these,  however,  become  infected,  there  is  periostitis  about  the 
middle  ear  and  mastoid  which  may  track  to  the  surface  or  spread 
into  the  cranium. 

Signs.  Deafness,  pain  in  the  ear,  which  may  be  agonizing  (often  causing 
the  deafness  to  pass  unnoticed),  and  tinnitus  are  constant  symptoms.  In 
severe  instances  there  may  be  high  fever,  and  in  children  signs  of  meningeal 
irritation  are  common,  vomiting,  retraction  of  the  head,  and  great  irrita- 
bility, which  subside  when  the  membrane  is  punctured  or  perforates.  The 
appearances  of  the  drum  vary  :  where  the  affection  is  slight  there  may  be 
injection  of  the  vessels  and  loss  of  polish  of  the  surface,  possibly  the  upper 
level  of  fluid  may  be  noted  within  altering  with  the  different  positions  of 
the  patient's  head.  Where  the  inflammation  is  severe  the  membrane  may 
be  dark  red,  oedematous,  and  bulging  outwards,  with  no  signs  of  the  handle 
of  the  malleus,  sometimes  bulla?  are  noted  on  its  surface. 

If  perforation  of  the  membrane  has  taken  place  pus  may  be  seen  exuding 
from  a  hole  at  the  end  of  a  nipple-shaped  projection  of  the  membrane. 
This  has  to  be  distinguished  from  a  polypus  of  the  inner  tympanic  wall 
covered  with  granulations  in  cases  where  the  membrane  has  been  destroyed 
by  previous  inflammation. 

The  slighter  cases  may  subside,  the  Eustachian  tube  becoming  patent 
again  and  serum  or  pus  being  absorbed.  In  the  more  severe  instances  the 
membrane  generally  gives  way  within  three  days,  with  great  relief  of  pain. 
There  is  a  discharge  of  pus  and  blood,  then  pus  alone,  and  finally  thin  serum, 
after  which  the  perforation  may  heal  up  if  small,  leaving  a  thin  scar,  or 
if  large,  remain  permanently  open  and  leaving  a  ready  point  of  access  for 
infections  to  the  middle  ear. 

In  many  cases,  however,  the  condition  passes  into  a  chronic  stage, 
especially  when  accompanying  the  exanthemata  and  where  there  is  persis- 
tent naso-pharyngeal  source  of  reinfection.  In  other  instances,  again, 
there  will  be  adhesions  of  the  membrane  to  the  inner  wall  of  the  tympanum, 
resulting  in  a  varying  degree  of  deafness.  Where  the  infection  is  very 
severe  it  may  spread  to  the  bones,  causing  mastoiditis,  subcranial  abscess, 
sinus,  thrombosis,  &c,  but  these  complications  are  more  usual  in  cases 
where  the  affection  has  become  already  chronic. 


SUPPURATIVE  OTITIS  MEDIA  611 

Treatment.  The  patient  should  be  confined  to  bed  on  light  diet,  the 
bowels  well  opened  with  calomel,  and  the  naso-pharynx  kept  as  clean  as 
possible  with  a  spray  of  menthol,  eucalyptol,  and  creosote,  10  grains  of 
each  to  the  ounce  of  parolein.  The  pain  may  be  relieved  by  instillation  of 
menthol  in  parolein  (5  per  cent.)  or  application  of  hot  flannels,  or  by  placing 
wool,  with  a  little  chloroform  in  the  central  part,  over  the  meatus  so  that 
the  vapour  pours  into  the  latter.  The  membrane  should  be  examined 
daily,  and  if  reddened,  cedematous  and  bulging,  especially  if  cerebral  irri- 
tation be  present,  should  be  opened,  under  a  general  anaesthetic,  by  an 
incision  in  the  lower  posterior  quadrant.  After  the  membrane  has  been 
perforated  by  nature  or  art,  the  meatus  is  cleaned  by  regular  gentle  syringing 
with  weak  carbolic  or  biniodide  solution  and  the  pus  sucked  out  through  the 
perforation  with  the  Siegle's  speculum,  after  which  boric  powder  is  insuf- 
flated into  the  meatus  or  a  light  pack  of  gauze  inserted  into  the  latter. 
When  the  acute  stage  has  passed  off  the  naso-pharyngeal  condition  should 
be  overhauled,  adenoids,  &c,  removed,  and  patency  of  the  Eustachian 
tube  restored  by  inflation.  With  due  care  many  cases  will  heal  well,  but 
the  more  severe  examples  are  likely  to  become  chronic. 

(3)  Chronic  Suppurative  Otitis  Media.  This  is  usually  a  sequel  to  acute 
otitis,  previously  described,  but  occasionally,  and  especially  in  children, 
arising  from  tuberculous  infection. 

This  affection  most  commonly  follows  the  acute  condition  arising  in 
scarlet  fever  or  measles  in  childhood,  being  uncommon  in  adults  except  after 
influenza  or  when  persisting  from  childhood.  Many  such  cases  persist  quietly 
for  years  and  suddenly  blaze  up,  with  disastrous  results,  from  intracranial 
complications.  A  chronic  suppuration  of  the  middle  ear  must  be  regarded 
in  the  same  light  as  a  diseased  appendix,  and  any  patient  with  this  affection 
is  in  a  precarious  condition  till  the  lesion  is  soundly  healed. 

Anatomy.  The  lining  membrane  of  the  middle  ear  and  antrum  is 
inflamed  and  constantly  secretes  pus.  The  inflammation  may  be  especially 
localized  to  one  part,  e.g.  the  epitympanic  space  (attic),  and  is  often  asso- 
ciated with  local  caries  of  bone,  e.g.  the  ossicles.  The  mucosa  is  converted 
into  granulation-tissue  to  a  greater  or  less  extent,  and  polypi  may  form. 
blocking  the  meatus;  the  membrana  tympani  is  perforated  or  completely 
destroyed. 

Signs.  There  is  usually  nothing  complained  of  excepl  persistent  purulent 
otorrhcea  and  a  varying  degree  of  deafness.  When  headache,  pain  over 
the  mastoid,  fever,  rigors,  &c,  occur,  the  case  must  be  regarded  as  urgent 
from  the  advent  of  some  complication. 

Inspection  through  the  meatus  reveals  one  or  more  perforations  dis- 
charging pus,  or  the  drum  may  be  so  completely  destroyed  thai  the  inner 
wall  of  the  promontory  and  the  ossicles,  if  still  present,  are  disclosed. 
Multiple  perforations  and  thin  discharge  suggest  tuberculous  infection.  In 
other  cases  the  view  will  be  obstructed  by  a  polypoid  mass  (pink)  or  a  white 
mass  if  choleadoma  be  present.  The  discharge  is  of  pus  with  a  sickly 
odour,  but  stinking  if  there  is  caries  of  the  bones  or  a  choleastoma.     Hearing 


.ill'  A  TEXTBOOK  OF  srucKIIY 

is  variously  affected,  often  being  completely  destroyed,   but   sometimes, 
especially  in  attic  suppuration,  little  affected. 

Treatment.  (1)  The  sources  of  re-infection  are  to  be  removed  from  nose 
and  pharynx  :  this  especially  applies  to  adenoids,  enlarged  and  unhealthy 
tonsils,  deviations  of  the  septum.  &c,  which  should  be  removed  and  the 
oaso-pharynx  afterwards  kept  clean  with  an  antiseptic  spray. 

(2)  The  general  health  is  improved  by  good  feeding,  tonics,  and  fresh 
air  :  in  these  cases  the  dry  air  of  mountains  is  preferable  to  the  moist 
air  of  the  sea. 

(3)  The  middle  ear  must  be  kept  clean  : 

(a)  By  softening  debris  and  cholesteatoma  by  instillation  of  hydrogen 
peroxide  (10  volumes)  ;  (b)  followed  by  syringing  daily  or  twice  daily 
with  solution  of  biniodide  of  mercury  1  in  5000 ;  (c)  and  drawing 
the  pus  out  of  the  deeper  pockets  with  the  pneumatic  speculum 
(Siegle)  or  driving  it  out  by  Politzer's  method  (to  ensure  free  drainage 
polypi  may  be  removed  or  the  ossicles  excised,  as  described  later). 
(d)  After  syringing  the  meatus  is  dried  and  boric  powder  insufflated,  or 
if  the  granulations  are  hypertrophic,  forming  small  polypi,  these  should 
be  reduced  by  instilling  a  solution  of  biniodide  of  mercury  1  in  2000  of 
50  per  cent,  spirit.  If,  when  these  measures  are  carefully  carried  out,  the 
condition  does  not  heal  in  six  months,  radical  operative  measures  (mas- 
toidectomy) should  be  carried  out,  as  there  is  probably  some  focus  of  caries 
present. 

Complications  of  chronic  otitis  media  are  discussed  in  a  later  section. 

(4)  Otosclerosis.  This  term  is  applied  to  fixing  of  the  foot  of  the  stapes 
in  the  fenestra  ovalis  so  that  its  movement  is  impaired  and  increasing 
deafness  results. 

The  condition  is  allied  to  osteo-arthritis,  and  osteophytes  are  to  be 
found  growing  from  the  stapes  and  fenestra. 

Signs.  Increasing  deafness  and  tinnitus  without  any  change  in  the 
membrana  tympani  and  no  blocking  of  the  Eustachian  tube.  The  deafness 
on  testing  is  of  the  middle-ear  type,  though  later  the  labyrinth  becomes 
involved  and  the  affection  assumes  the  internal-ear  type. 

Treatment  is  unsatisfactory  ;  inflation  of  the  middle  ear  or  moving  the 
drum  (and  the  stapes)  with  a  pneumatic  masseur  may  cause  temporary 
improvement,  but  the  course  is  progressive  to  complete  deafness  with 
periods  of  remission.  Deafness  resulting  from  healed  adhesive  or  sup- 
purative otitis  media  is  diagnosed  by  the  deafness  being  of  the  middle- 
ear  type,  by  there  being  absence  of  wax  in  the  meatus,  the  drum 
showing  scars  and  adhesions  to  the  promontory,  and  is  often  improved 
by  inserting  a  small  pellet  of  wool  moistened  with  saline  till  it  just 
touches  the  membrane  (Yearsley).  This  is  the  most  practical  form  of 
"  artificial  drum." 

Complications  of  Suppurative  Otitis  Media.  These  usually  are 
found  in  the  course  of  the  chronic  suppurative  disease,  and  may  be  divided 
into  cranial  and  intracranial. 


POLYPI.    CHOLESTEATOMA.    FACIAL  PARALYSIS  613 

(1)  Cranial  complications  are  :  (a)  polypi,  (b)  cholesteatoma,  (c)  facial 
paralysis,  (d)  mastoiditis,  and  caries  of  the  temporal  bone. 

(2)  Intracranial  complications  are  :  (a)  pachymeningitis,  (6)  lepto- 
meningitis, (c)  thrombosis  of  the  lateral  sinus,  (d)  encephalitis  and  cerebral 
abscess. 

(I)  Cranial  Complications  of  Otitis  Media,  (a)  Polypi  are  the 
result  of  prolonged  suppuration,  and  consist  of  masses  of  granulation-tissue 
covered  with  a  thin  layer  of  epithelium.  They  take  origin  from  the  inner 
wall  of  the  tympanum,  occasionally  from  the  ossicles.  In  appearance  they 
are  rounded,  smooth,  pink  masses  varying  in  size  from  a  pin's  head  to  a 
hazel-nut.  When  large  they  interfere  with  the  drainage  of  the  otorrhoea, 
of  which  they  are  the  result,  and  are  distinguished  from  exostoses  by  yielding 
to  the  probe. 

Treatment.  After  instilling  cocain  into  the  middle  ear  they  may  be 
removed  with  the  snare  if  large,  the  base  being  cauterized  a  few  days  later 
with  a  bead  of  chromic  acid  fused  on  the  end  of  a  probe  ;  if  small,  they 
may  simply  be  cauterized.  The  most  careful  asepsis  should  be  employed 
in  these  apparently  slight  operations,  as  intracranial  complications  some- 
times follow  the  removal  of  polypi.  After  removal  of  polypi  the  treatment 
for  chronic  suppurative  otitis  is  continued. 

(b)  A  cholesteatoma  consists  of  a  cheesy  mass  of  laminated  structure, 
whitish-yellow  colour  and  evil  odour,  found  in  the  middle  ear  or  mastoid 
antrum  and  cells  in  cases  of  old-standing  otitis  media.  In  most  cases  the 
condition  is  due  to  ingrowth  through  a  perforation  of  squamous  epithelium 
from  the  meatus,  which  covers  denuded  areas  of  the  middle  ear  (resulting 
from  severe  inflammation)  and  then  desquamates,  forming  balls  of  the 
above  character,  for  on  examination  degenerating  epithelial  cells  are  found 
in  these  masses.  In  other  instances  they  may  simply  be  masses  of  inspis- 
sated debris  resulting  from  caries.  The  formation  of  a  cholesteatoma  leads 
to  pressure-atrophy  of  the  surrounding  bone,  so  that  the  mastoid,  for 
example,  may  be  greatly  excavated  and  full  of  a  quantity  of  this 
substance. 

Diagnosis  is  made  by  finding  masses  of  whitish  material  protruding  from 
the  middle  ear,  and  it  may  be  suspected  in  old-standing  cases  with  a  foul 
discharge.  This  condition  is  very  important,  as  it  keeps  up  a  persistent 
source  of  infection,  prevents  proper  cleansing  of  the  middle  ear.  and  by 
causing  absorption  of  surrounding  bone  leads  to  perforation  of  the  skull 
and  intracranial  complications. 

Treatment.  Complete  mastoidectomy  should  be  performed  as  soon  as 
the  cholesteatoma  is  diagnosed,  but  in  many  instances  it  will  only  be  dis- 
covered in  the  course  of  an  operation  for  inveterate  middle-ear  disease. 

(c)  Facial  paralysis  occurring  in  the  course  of  otitis  media  implies  invasion 
of  the  aqueduct  of  Fallopius  by  inflammatory  products,  less  often  a  sclerosis 
of  the  bone,  and  this  is  easy  to  understand  on  reflecting  that  the  nerve  is 
in  close  proximity  to  the  junction  of  the  attic  and  tympanum  and  covered 
by  a  sheet  of  bone  of  the  thickness  of  notepaper. 


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A  TEXTBOOK  OF  Sl'ROKRY 


a  - 


Treatment.    Complete  mastoidectomy  should  be  done  a1  once  in  such  a 

aa  early  operation  gives  a  good  prospect  of  cure  of  the  paralysis. 
((/)  Affections  of  the  bone  arising  from  chronic  suppurative  otitis  media 
(caries  of  the  ossicles,  temporal  bone,  and  mastoid). 

Caries  of  these  osseous  structures  may  occur  separately  or  together. 

(I)  The  ossicles,  or  at  any  rate  the  mallerus  and  incus,  in  severe  instances 

of  otitis  may  become  necrosed  and  discharged  through  a  large  perforation 

which  destroys  most  of  the  drum.     Small  localized  patches  of  caries  oi 

the  heads  of  these  hones  may  maintain  suppuration  in  the  attic,  requiring 

removal  of  the  ossicles  or  mastoidectomy. 
In  the  former  condition  with  large  perfo- 
ration the  otitis  may  heal  after  the  ossicles 
have  separated,  leaving  a  large  permanent 
perforation. 

(2)  Caries  of  the  temporal  bone  varies 
in  severity  and  distribution  ;  there  may 
be  a  small  patch  of  caries  on  the  inner 
wall  of  the  middle  ear,  appreciable  with  a 
probe,  or  necrosis  of  large  portions  of  the 
petrous  and  squamous  bones  as  found  in 
severe  scarlatinal  and  tuberculous  cases. 
When  the  infection  spreads  to  the  internal 
ear  the  condition  known  as  labyrinthitis 
is  set  up.      Labyrinthitis  may  be  due  to 

thrombosis,     a,  Tentorium,     b.  Di-     caries  spreading  through  the  bone  or  in- 
gastnc   muscle.      e,    Sternomastoid.  .r       ,  ■>  T      •    i 

d,  Diseased  mastoid  connected  with    vasion  by  the  oval  or  round  windows;   it 
,.  Mastoid  abscess.    /.  Lateral  sinus,     occurs  especiallv  where  there   is  a  chole- 

which  is  partly  thrombosed.  x  . ,     -„ 

steatoma.  and  is  likely  to  lead  to  menin- 
gitis and  cerebellar  abscess.  The  symptoms  of  invasion  of  the  internal  ear 
are  vertigo,  nystagmus,  and  sometimes  vomiting  and  headache. 

Treatment.  All  these  conditions  call  for  exploration  by  the  mastoid 
route  and  thorough  removal  of  carious  bone. 

(.*>)  Mastoiditis  is  a  variety  of  caries  of  the  temporal  bone  requiring 
special  mention  owing  to  its  frequency  and  the  definiteness  of  its  clinical 
signs.  The  mucous  membrane  of  the  mastoid  antrum  is,  no  doubt,  affected 
and  secretes  pus  like  the  rest  of  the  middle  ear  in  cases  of  otitis  media, 
but  unless  the  bone  is  affected  the  condition  is  not  mastoiditis,  which 
implies  caries  or  necrosis  of  the  bone  of  varying  severity  around  the  mastoid 
antrum.  This  may  be  due  to  the  ordinary  pyogenic  organisms  or  the 
tubercle  bacillus. 

Anatomy.  In  the  acute  cases  there  is  great  congestion  of  the  bone 
with  rapid  formation  of  pus  in  the  diploic  and  air-cells  and  stripping  of  the 
surface  periosteum  of  the  mastoid,  resulting  in  a  mastoid  abscess  (extra- 
cranial) ;  if  the  infection  spreads  inwards  through  the  bone  there  may  be 
a  collection  of  pus  on  its  deep  surface  in  the  posterior  fossa  around  the 
lateral  sinus  (extradural  or  subcranial  abscess)  and  further  complications, 


I'n..  239.      Coronal  section  through 
the  skull    in  mastoiditis   and    sinus 


MASTOIDITIS  615 

such  as  thrombosis  of  the  sinus,  meningitis  or  cerebral  abscess,  may  arise ; 
or  the  infection  may  spread  forward  in  the  petrous  and  squamous  bones. 
In  the  chronic  cases  there  is  little  destruction  of  bone  but  much  sclerosis, 
and  laying  down  of  new  dense  bone,  the  wall  of  the  mastoid  being  eburnated 
and  as  much  as  an  inch  thick,  the  antrum  being  reduced  to  a  mere  chink 
and  difficult  to  find  at  operation  except  by  exploring  back  along  the  adit 
from  the  middle  ear. 

In  tuberculous  cases  the  process  is  one  of  quiet  caries,  the  bone  being 
replaced  by  weak  granulation-tissue  spreading  through  the  mastoid  and 
surrounding  bones  till  the  whole  is  widely  excavated  and  a  chronic  abscess 
appears  behind  the  ear. 

Signs,  (a)  Acute  Mastoiditis.  This  develops  most  often  in  a  case  of 
chronic  otitis  media  of  short-standing,  seldom  occurring  while  inflammation 
of  the  middle  ear  is  acute  except  in  influenzal  or  scarlatinal  cases,  i.e.  as 
a  rule  several  weeks  elapse  after  the  onset  of  otitis  media  before  the  mastoid 
is  involved  ;  but  acute  mastoiditis  may  develop  after  years  of  chronic  middle- 
ear  disease.  The  onset  is  sudden  in  a  patient  suffering  from  suppurative 
otitis  media,  with  pain  in  the  ear,  high  fever,  tenderness  over  the  mastoid, 
which  later  becomes  red,  cedematous,  and  boggy  if  a  subperiosteal  abscess 
forms.  The  otorrhcea  may  remit  with  the  advent  of  these  symptoms,  and 
in  some  cases,  especially  of  children,  meningeal  irritation  is  marked  (head- 
retraction,  photophobia,  and  screaming).  On  examining  the  auditory 
meatus,  various  conditions  of  previous  otitis  media  are  noted,  such  as  per- 
forations of  the  drum,  polypi,  &c,  while  a  very  important  early  sign  is  a 
bulging  of  the  upper  posterior  part  of  the  wall  of  the  bony  meatus,  the 
cause  of  which  is  oedema  (similar  to  that  over  the  mastoid). 

In  well-marked  instances  the  oedema  or  abscess  over  the  mastoid  pushes 
the  ear  forwards  and  downwards.  Occasionally  (never  in  children  because 
of  the  slight  development  of  the  mastoid  process)  the  inflammation  spreads 
to  the  inner  or  deep  aspect  of  the  mastoid  process,  which  gives  way  there 
and  pus  escapes  into  the  digastric  fossa  ;  this  is  known  as  v.  Bezold's 
mastoiditis,  and  there  will  be  found  swelling,  and  possibly  fluctuation 
under  the  upper  part  of  the  sternomastoid  muscle.  Signs  resulting  from 
spread  into  the  cranial  fossae  are  discussed  later. 

Diagnosis  has  to  be  made  from  furuncles  of  the  auditory  meatus  and 
inflammatory  enlargement  of  the  mastoid  glands. 

In  furunculosis  there  is  often  oedema  over  the  mastoid,  but  this  process 
is  not  tender  ;  on  the  contrary,  the  main  tenderness  is  in  front  of  the  meatus, 
and  inspection  of  the  meatus  will  disclose  the  furuncle. 

Inflamed  mastoid  glands  usually  result  from  sores  on  the  scalp,  and 
produce  a  swelling  rather  behind  than  over  the  mastoid,  while  the  ear, 
even  if  pushed  forwards  by  oedema,  will  not  be  displaced  downwards  and 
the  meatus  and  membrane  will  appear  normal. 

V.  Bezold's  mastoiditis  may  be  difficult  of  diagnosis,  as  the  main  swelling 
is  below  the  mastoid  though  partly  over  the  latter.  The  occurrence  of  a 
boggy  swelling  in  this  situation  associated  with  old-standing  otitis  media 


616 


A  TEXTBOOK  OF  SURGERY 


will  suLrLr<'>t  this  condition,  hut  exploration  may  lie  Deeded  before  certainty 
is  attained. 

(b)  Chronic  mastoiditis  may  present  no  external  signs,  the  bone  being 
Etimply  sclerosed  and  remaining  undiscovered  till  operation  for  inveterate 
suppurative  otitis  is  done  or  from  the  development  of  intracranial  compli- 
cations or  the  perforation  of  the  bone,  as  in  v.  BezokFs  type.  In  other 
cases  the  condition  is  very  like  the  acute  form,  a  boggy  or  fluctuating  swelling 

appearing  over  the  mastoid  which  pushes  the 
auricle  downward  and  forward,  but  with  little 
pain  and  tenderness  and  slight  constitutional 
disturbance. 

Treatment  of  all  these  conditions  is  ope- 
rative and  is  discussed  in  the  next  section. 

Operative  Treatment  for  Severe  or  Inveter- 
ate Middle-Ear  Suppuration  and  its  Cranial 
Complications.  This  implies  opening  the  mas- 
°     toid  antrum  in  all  cases  with  the  exception 
of  polypi,  the  treatment  of  which  has  been 
6     described,  and  if  after  removal  of  polypi  the 
otitis  persists,  operation  on  these  lines  will 
flf     be  needed  later.    The  object  of  the  operation 
is  to  remove  dead  or  dying  infective  material, 
such  as  bone  or  cholesteatoma,  and  provide 
C     efficient  drainage  till  the  cavity  is  healed  over 
with  epithelium. 

Two  operations  are  performed  for  these 
conditions,  according  to  the  severity  and 
chronicity  of  the  disease  : 

(1)  Antral  drainage  or  Schwartze's  opera- 
tion, in  which  the  mastoid  antrum  is  opened 
and  drained  but  the  middle  ear  left  to 
heal. 

(2)  Staeke's  operation,  sometimes  called 
radical  or  mastoidectomy,  in  which  the  middle  ear  and  antrum  are  laid 
into  one  cavity,  ossicles  and  drum  removed,  and  drainage  being  effected 
through  a  permanently  enlarged  external  auditory  meatus.  A  short  list  of 
the  indications  for  these  operations  may  be  useful  (Tod)  : 

(1)  For  Antral  Drainage  (Schwartze).  (a)  This  operation  is  seldom 
employed  except  for  complications  of  recent  otitis. 

(b)  During  the  acute  stage  if,  after  paracentesis  or  perforation  of  the 
drum  with  good  drainage,  there  is  persistent  earache,  headache,  fever,  and 
tenderness  over  the  mastoid  lasting  more  than  three  days. 

(c)  For  obvious  acute  mastoid  abscess  as  described  above. 

(d)  A\  here  in  spite  of  good  drainage  meningeal  symptoms  persist. 

(e)  Where  after  a  month  discharge  is  profuse  and  there  is  a  bulging  of 
the  posterior  wall  of  the  bony  meatus. 


FlO.  240.  Coronal  .section  through 
the  mastoid  in  mastoiditis.  (V.  Be- 
zold's type.)  a,  Tentorium,  b,  l>i- 
gastric  fossa  and  muscle,    r.  Sterno- 

mastoid.   <!,  Abscess  internal  to  the 
id.     e.  Diseased  and  excava- 
ted mastoid. 


OPERATIONS  FOR  MASTOIDITIS,  CHRONIC  OTITIS  MEDIA    617 

(/)  After  two  months  if  discharge  is  still  profuse  in  spite  of  treatment, 
as  there  is  probably  a  large  antral  cavity  and  poor  drainage  through  the 
aditus. 

(2)  For  Mastoidectomy  (Stacke).  (a)  As  a  prophylactic  measure  in 
cases  where  otorrhoea  has  persisted  in  spite  of  treatment  for  a  year. 

(b)  Where  polypi  recur  after  removal  and  otitis  persists. 

(c)  Where  free  escape  of  the  discharge  is  prevented  from  stenosis  of  the 
meatus  or  exostoses. 

(d)  Where  there  is  a  fistula  over  the  mastoid  from  bursting  of  an  abscess 
or  antral  drainage,  which  will  not  heal. 

(e)  For  tuberculosis  of  the  mastoid,  as  evidenced  by  multiple  perforations 
and  weak  anaemic  granulations. 

(/)  Cases  of  acute  mastoid  abscess  arising  from  old-standing  otitis. 

(g)  Involvement  of  the  internal  ear,  shown  by  giddiness,  vomiting, 
headache. 

(h)  Facial  paralysis. 

(i)  Intracranial  complications,  to  which  this  operation  is  a  useful  intro- 
duction or  a  necessary  conclusion. 

Danger-signals  indicating  that  operative  measures  are  urgent  are  high 
fever  and  rigors,  facial  paralysis,  severe  pain  in  the  mastoid  or  general 
headache,  loss  of  bone-conduction  on  the  affected  side,  vertigo,  and  vomiting. 

Operation.  As  the  more  radical  attack  is  only  a  development  of  the  less 
severe  antral  drainage,  these  operations  may  be  described  together. 

The  anaesthetized  patient  lies  with  the  shoulder  on  the  affected  side 
raised  and  the  base  of  the  skull  well  over  on  the  side  and  steadied  with  a 
soft  sand-bag  underneath.  The  half-scalp  is  shaved  and  cleaned  with 
iodine  solution  in  spirit,  including  the  ear,  auditory  meatus,  and  neck. 

The  mastoid  region  is  exposed  by  a  curved  incision  down  to  the  bone, 
starting  just  above  the  attachment  of  the  ear  to  the  scalp  and  running  back 
half  an  inch  behind  the  attachment  of  the  ear  to  the  tip  of  the  mastoid 
process.  This  flap  is  raised  forwards  with  the  rugine  till  the  opening  of 
the  bonv  meatus  and  the  cartilaginous  meatus  leading  to  this  are  clearly 
exposed.  The  position  of  the  antrum  is  marked  on  the  surface  by 
the  depression  between  the  ridge  forming  the  back  of  the  external  bony 
meatus  and  the  backward,  horizontal  extension  of  the  zygoma.  The  bone 
is  cut  away  freely  in  this  situation  with  gouges,  of  which  the  corners  are 
rounded  so  as  not  to  cut  the  dura,  and  the  antrum  will  be  found  at  a  depth 
of  one-eighth  to  three-quarters  of  an  inch  from  the  surface  proceeding  in 
a  direction  up  and  back  from  the  antral  depression  already  mentioned. 
The  opening  should  be  large  on  the  surface  or  there  may  be  difficulty  later. 
There  is  considerable  chance  of  exposing  the  lateral  sinus  at  the  back  of 
the  middle  fossa  at  the  upper  part  of  the  excavation  in  the  bone  ;  this  is 
of  no  disadvantage  if  the  dura  be  not  wounded  and  is  often  advantageous 
in  obscure  cases,  as  showing  the  presence  or  not  of  an  extradural  abscess 
oi  affection  of  the  sinus.  In  some  cases  where  the  antrum  is  reduced  in  size 
by  surrounding  sclerosis  it  will  be  found  actually  above  the  floor  of  the 


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A  TEXTBOOK   OF SUROERY 


outer  part  of  the  middle  fossa  and  behind  the  foremosl  pari  of  the  lateral 
sinus.  In  manv  cases  the  antrum  is  easily  found  by  tracing  a  collection  of 
]uis  in  the  lx»no  inwards  till  it  is  reached,  and  is  distinguished  from  ordinary 
bone-cells  which  surround  it  by  detecting  with  a  curved  dissecting  tool 
the  presence  of  the  aditus  in  front,  leading  forward  into  the  attic  of  the 
middle  ear.  In  all  cases  the  antrum  should  be  found  and  surrounding  carious 
bone  removed,  which  may  include  a  large  part  of  the  mastoid  process.    If 

it  is  decided  that  drainage  of  the  antrum 
will  meet  the  requirements  of  the  case  the 
operation  is  now  complete,  the  antrum  is 
packed  with  gauze,  and  the  incision  behind 
the  ear  sutured  almost  completely,  leaving 
an  exit  for  the  gauze.  The  plug  is  removed 
on  the  second  day  and  the  antrum  and 
middle  ear  are  syringed  out  daily  with  dilute 
antiseptic  lotion,  the  gauze  being  replaced 
for  about  a  week,  wThen  it  is  left  out  and 
the  aperture  allowed  to  close,  irrigation 
being  maintained  daily  till  this  occurs, 
when  the  treatment  is  continued  as  for 
otitis  media. 

Note.  In  infants,  in  whom  there  is 
no  mastoid  process  and  the  facial  nerve 
comes  out  at  the  side  and  not  below  as 
in  adults,  the  original  skin  incision  must 
not  be  down  to  the  bone  at  its  lower  ex- 
tremity or  the  nerve  may  be  cut. 

In   cases   where   it  is  decided  that  a 

more  complete  operation  (mastoidectomy, 

Stacke's  operation)  is  needed  the  skin-flap 

is  dissected  more  thoroughly  forwards  and  the  cartilaginous  separated  from 

the  bony  meatus,  the  antrum  being  opened  as  before. 

If  there  is  difficulty  in  finding  the  antrum,  the  posterior  wall  of  the  bony 
meatus  may  be  removed  and  then  the  outer  wall  of  the  middle  ear  and 
aditus,  which  can  thus  be  traced  back  to  the  antrum  (this  was  the 
original  method  used  by  Stacke).  In  any  case  the  barrier  of  the 
posterior,  wall  of  the  meatus  is  removed,  thus  laying  the  antrum,  aditus, 
and  middle  ear  into  one  cavity.  Special  care  is  needed  while  cutting 
away  the  deeper  part  of  the  outer  wall  of  the  aditus,  for  the  facial  nerve 
lies  just  beneath  this  and  may  be  readily  injured  as  it  lies  in  the  aqueduct 
of  Fallopius ;  such  an  injury  is  disclosed  by  a  convulsive  twitch  of 
the  face  on  that  side.  The  next  step  is  to  remove  polypi,  granu- 
lations, carious  ossicles — leaving,  however,  if  possible,  the  stapes,  as  its 
removal  will  lead  to  spread  of  infection  to  the  internal  ear.  During  this 
stage  and  most  of  the  operation  repeated  swabbing  with  strips  of  gauze  and 
the  use  of  a  head-lamp  are  essential.     Next,  the  walls  of  the  cavity  thus 


Fig.  241.     ab,  Incision  for  exploring 

the  mastoid  and  middle  car.  c.  External 

auditory  meatus,     d,  Tip  of  mastoid. 

e,  Incision  backwards  to  reach  lateral 

sinus  or  cerebellum. 


MASTOIDECTOMY 


619 


laid  open  must  be  searched  for  fistula?  leading  into  the  cerebral  fossa?, 
removing  carious  bone  on  the  various  aspects  till  there  is  no  chance  of  such 
a  condition  being  overlooked.  Where  fistula?  are  found  the  opening  should 
be  enlarged  and  traced  back  into  the  cranium,  establishing  free  drainage  ; 
fairly  often  a  large  fistula  will  be  found  leading  to  one  of  the  fossa?  with 
considerable  collection  of  pus  outside  the  dura,  producing  no  intracranial 
signs  but  accounting  for  an  excessive  amount  of  discharge  from  the  ear. 
Where  any  acute  symptoms  are  present  the  opening  should  be  carried  up 
and  back  so  that  both  middle  and  posterior  fossa?  are  opened  and  the  dura 
and  lateral  sinus  examined.  Where  caries  of  the  labyrinth  is  present  this 
must  be  carefully  removed,  guarding  the  facial  nerve.  If  the  dura  of  either 
fossa  is  raised  by  effusion  of  pus  and  covered  with  healthy  granulations  it  may 


Fig.  242.     Section  of  skull  and  car,  showing  the  concho-mcatal  flap  a,  in  position  on 

the  outer  wall,  and  the  skingraft  b  lining  the  inner  wall.     B,  Skin  flap  cut  from  the 

concha  to  line  the  antrum  (Ballance).     The  dotted  line  shows  the  free  slitting  up  of 

the  external  auditory  meatus. 

be  left  to  recover  under  drainage,  but  where  the  wall  of  the  lateral  sinus  is 
sloughy,  even  if  there  are  no  signs  pointing  to  thrombosis,  this  complication 
will  surely  follow  shortly,  and  the  sinus  must  be  treated  as  if  already  throm- 
bosed (see  Thrombosis  of  Sinuses).  When  all  carious  bone,  polypi,  cholestea- 
toma,  debris,  &c,  have  been  removed  from  the  antrum  and  middle  eai 
the  cavity  is  smoothed  with  gouge  or  burr  (for  better  epithelialization  later) 
and  arrangements  made  to  ensure  good  drainage.  This  may  be  done 
through  the  specially  enlarged  external  meatus  where  there  are  no  greater 
complications  than  extradural  abscess,  but  where  there  are  severe  intra- 
cranial complications  it  will  often  he  better  if  part  at  least  of  the  drainage  is 
through  the  wound  over  the  mastoid.  To  enlarge  the  meatus,  this  is  split 
back  with  a  bistoury  till  it  will  admit  the  first  finger  readily  :  the  posterior 
auricular  artery  is  divided,  but  can  readily  be  checked  by  clamping  for  a 
few  minutes  while  the  rest  of  the  operation  is  finished.  This  consists  in 
cutting  a  skin-flap  from  the  inside  of  the  concha  (Ballance)  and  turning  it 


620  A  TEXTBOOK  OF  SURGERY 

round  so  that  its  raw  surface  is  applied  to  the  deep  surface  of  the  original 
mastoid  flap,  where  it  is  retained  by  a  suture.  This  will  ensure  the  meatus 
not  contracting  again  too  readily  ;  the  cartilage  laid  bare  in  the  concha 
by  turning  up  the  little  flap  is  removed,  or  it  will  slough.  The  middle  ear, 
adit  us.  and  antrum  arc  packed  tight  with  gauze  through  the  enlarged  meatus 
and  the  original  wound  over  the  mastoid  sutured  completely.  The  gauze 
is  removed  on  the  third  day  and  replaced  after  irrigation,  and  this  repeated 
till  the  wound  is  clean  and  granulating  nicely.  At  this  point,  i.e.  in  about 
ten  to  twenty  days,  the  posterior  wound  is  opened  again  and  a  large  Thiersch 
skin-graft  inserted  to  cover  the  inner  raw  surface  of  the  cavity  of  the  middle 
ear  and  antrum  and  packed  in  position  with  gauze,  the  end  of  which  comes 
out  through  the  meatus,  and  the  wound  closed  again. 

The  pack  may  be  left  in  for  a  week,  after  which  time  the  graft  should  be 
adherent  and  the  cavity  practically  healed.  A  few  granulations  will  need 
touching  with  silver  nitrate  or  chromic  acid,  and  the  cavity  should  be  kept 
clean  by  occasional  syringing  after  it  is  healed.  This  method  of  grafting 
(Ballance)  reduces  the  time  of  healing  from  months  to  weeks,  for  the  natural 
process  of  epithelization  of  the  large  cavity  from  the  edges  of  the  meatus 
is  naturally  slow  :  the  after-results  as  to  hearing  are  satisfactory. 

(2)  Intracranial  Complications  of  Otitis  Media  (with  which  are 
included  intracranial  inflammations). 

These  may  be  divided  into  :  (a)  Inflammations  of  the  dura,  especially 
of  its  outer  surface  (pachymeningitis  externa,  extradural  abscess) ;  (b)  in- 
flammations between  the  dura  and  the  brain  (arachnoiditis,  lepto- 
meningitis, subdural  abscess)  ;  (c)  infections  of  sinuses  (sinus  thrombosis)  ; 
(d)  infections  of  the  brain  (encephalitis  and  cerebral  abscess). 

In  practice  two  or  more  of  these  conditions  may  be  present  together. 

(a)  Pachymeningitis.  (1)  Inflammation  of  the  dura  of  a  chronic  nature 
appears  to  be  caused  by  repeated  injuries,  alcohol  and  syphilis,  leading  to 
headache  and  mental  impairment,  probably  from  being  associated  with  a 
similar  condition  of  the  subdural  tissues. 

(2)  Acute  infective  pachymeningitis  or  extradural  abscess  may  result 
from  : 

(a)  Injury,  usually  in  a  case  of  depressed  or  punctured  compound 
fracture,  less  often  from  infection  of  a  subcranial  clot  without  fracture. 

(b)  More  often  as  a  complication  of  middle-ear  disease,  with  caries  of 
the  temporal  bone,  mastoiditis,  &c,  the  process  spreading  till  the  cranial 
fossa  is  reached,  when  it  may  remain  chronic  or  spread  to  the  subdural 
space  or  brain. 

Signs,  (a)  There  is  nearly  always  a  wound  of  the  scalp,  under  which 
there  is  usually  a  depressed  or  punctured  fracture  (the  latter  an  insidious 
condition).  The  patient  will  have  high  fever,  rigors  (due  to  osteomyelitis 
of  the  bone),  and  at  the  seat  of  the  injury  there  will  be  a  tender,  cedematous 
swelling  (Pott's  puffy  tumour),  while  the  edges  of  the  wound  will  be  unhealthy 
and  swollen  and  bare  dead  bone  may  be  found  under  it.  Signs  of  intra- 
cranial pressure,  headache,  and  later  coma  or  focal  signs  (fits,  paralyses) 


EXTRADURAL  ABSCESS.    LEPTOMENINGITIS  621 

may  be  noted.  The  condition  is  grave — far  rnoie  so  than  that  of  extra- 
dural abscess  consecutive  to  otitis  media.  Pott,  who  first  described  the 
lesion,  saved  several  cases,  but  other  surgeons  have  been  less  fortunate,  the 
probable  reason  being  that  many  of  these  cases  are  really  more  than  extra- 
dural abscesses,  the  infection  having  already  spread  to  the  subdural  tissues 
by  direct  infection  or  through  some  small  wound  of  the  dura.  Pyaemia 
from  the  associated  cranial  osteomyelitis  accounts  for  some  fatal  cases. 

Treatment.  The  site  of  injury  should  be  freely  exposed,  the  skull  opened 
widely,  dead  bone  removed,  and  the  underlying  dura  carefully  investigated. 
If  simply  inflamed  and  secreting  pus,  the  latter  may  be  removed  and 
drainage  established,  but  if  the  dura  is  necrotic  or  there  are  signs  of  effusion 
underneath,  especially  with  signs  of  leptomeningitis — as  fits,  head-retraction, 
photophobia,  &c. — the  dura  should  be  opened  and  the  underlying  tissues 
explored  and  freely  drained. 

(b)  When  arising  in  the  course  of  suppurative  otitis  media  there  may  be 
no  signs,  though  if  the  discharge  be  very  profuse  this  condition  may  be 
suspected.  Where,  however,  the  escape  of  pus  is  blocked,  causing  the 
intracranial  pressure  to  rise,  there  will  be  headache,  stupor  passing  into 
coma,  possibly  fever,  fits,  giddiness  or  paralyses,  though  these  are  unusual. 

Treatment.  When  discovered  in  the  course  of  mastoidectomy  it  is  only 
necessary  to  enlarge  the  fistulous  opening,  freely  exposing  the  dura  and 
securing  free  drainage,  when  the  dura  will  become  covered  with  healthy 
granulation-tissue  and  epithelium  like  the  rest  of  the  cavity. 

Where  there  are  signs  of  cerebral  pressure  the  treatment  is  very  similar. 
the  opening  in  the  bone  over  the  mastoid  being  freely  enlarged  to  secure 
sure  drainage  of  the  fossa  implicated,  and  it  will  be  well  to  drain  behind 
the  ear  for  a  few  days  till  urgent  signs  have  passed  off,  when  the  meatus 
may  be  enlarged  and  the  concha!  flap  be  cut  as  usual. 

(b)  Subdural  Inflammations.  These  may  be  chronic,  subacute  or  acute, 
and  localized  or  diffuse. 

(1)  Chronic  Arachnoiditis  or  Lej)to-meningitis.  This  consists  of  a  fibrous 
thickening  of  the  arachnoid  and  pia  mater  usually  associated  with  a  similar 
condition  of  the  dura,  which  has  been  already  mentioned  as  due  to  trauma, 
syphilis,  organizing  of  subdural  blood-clot  after  fractures  of  the  skull,  &c. 
(p.  595.) 

Signs.    Headaches,  mental  weakness,  sometimes  fits,  or  other  focal  signs. 

Treatment.  Mercury  and  iodides,  beneficial  in  syphilitic  cases,  may  also 
be  of  service  in  the  traumatic  variety,  in  which  the  question  of  operation 
may  be  raised  (see  later  Epilepsy,  p.  <>32). 

(2)  Subacute  inflammations  of  the  arachnoid  and  pia  are  diffuse,  due 
to  infection  with  the  tubercle  bacillus,  and  only  need  a  short  notice  here, 
being  fully  described  in  works  on  internal  medicine.  The  disease  usually 
occurs  in  children,  who  often  are  affected  with  some  other  tuberculous 
lesion  of  joint,  lung,  glands,  &c.  It  comes  on  insidiously  with  headache, 
vomiting  of  the  cerebral  type,  constipation,  wasting,  and  later  fits,  retrac- 
tion of  the  head,  paralyses,  and  ends  with  coma. 


622  A  TEXTBOOK  OF  SURGERY 

Diagnosis.  When  fully  developed  this  is  tolerably  clear,  but  in  the 
earlier  Btages  the  signs  may  be  somewhat  indefinite.    The  surgical  condition 

most  likely  to  be  confused  with  this  disease  is  intestinal  obstruction.  o\\  iug  to 
the  obstinate  vomiting  and  constipation;  but  the  wasted  and  retracted 
*'  boat-like  '*  abdomen,  the  slow  pulse  and  mental  confusion  or  irritability 
and  delirium,  and  the  irregular  fever  will  decide  on  closer  examination  of 
the  patient. 

ks  the  disease  is  usually  a  manifestation  of  generalized  miliary  tubercu- 
losis, local  measures  are  not  likely  to  be  beneficial ;  attempts  have  been 
made  to  relieve  the  intracranial  pressure  by  opening  the  skull  freely,  but 
the  results  are  disappointing  and  such  treatment  is  at  present  purely 
experimental. 

(3)  Acute  inflammations  of  the  subdural  space  are  due  to  infection  with 
pyogenic  organisms,  streptococci  and  pneumococci  in  chief,  which  arrive 
via  the  middle  ear  from  chronic  disease  of  the  latter  or  from  injuries  of  the 
skull,  usually  depressed  compound  fractures,  being  then  an  extension  of 
the  extradural  infection  described  in  a  previous  section,  p.  020) 

In  most  instances,  owing  to  the  slight  powrer  of  the  meninges  to  form 
protective  adhesions,  the  inflammation  is  spread  over  the  surface  of  the 
brain  as  a  diffuse  leptomeningitis  or  meningo-encephalitis  ;  more  rarely  it 
remains  localized  as  a  subdural  abscess  which  may  be  combined  with  a 
superficial  cerebral  abscess.  In  some  cases  the  infection  passes  into  the 
brain  with  but  little  affection  of  the  meninges,  which  form  protective  adhe- 
sions around,  giving  rise  to  a  deep  cerebral  abscess,  the  point  of  entrance  to 
the  brain  being  marked  by  a  few  adhesions. 

(a)  Acute  spreading  infection  beneath  the  dura  (acute  lepto-meningitis) 
may  result  from  injuries  to  the  skull  (usually  penetrating),  operations  where 
the  dura  is  opened  through  infected  tissues,  or  by  spread  from  suppuration 
of  the  middle  ear,  mastoid,  sphenoidal  and  frontal  sinuses,  occasionally 
from  erysipelas  or  carbuncle  of  the  face. 

Anatomy.  The  pia-arachnoid  is  congested  and  filled  with  purulent 
exudate  which  extends  down  the  spinal  cord  in  the  subdural  space,  while 
the  surface  of  the  brain  is  congested  and  infiltrated. 

Signs.  The  onset  is  sudden,  usually  within  forty-eight  hours  in  case 
of  injury,  or  at  any  time  in  a  case  of  suppurative  otitis  media,  in  wrhich  case 
it  may  be  preceded  by  a  history  of  cessation  of  the  discharge  from  the  ear. 
There  are  violent  headache,  high  fever,  possibly  an  initial  rigor,  vomiting  of 
the  cerebral  type,  the  pulse  full,  rapid  and  bounding,  twitching  of  muscles 
and  fits  where  the  hemispheres  are  more  affected,  retraction  of  the 
head,  ocular  paralyses,  and  rigidity  of  the  spine  where  the  base  is  the 
main  site  of  the  lesion.  Photophobia  and  irritability  are  marked, 
while  delirium,  followed  by  stupor  and  coma,  terminates  the  disease, 
usually  within  four  days  of  the  onset.  In  other  examples,  e.g.  where 
there  is  a  fungating  hernia  cerebri,  the  case  may  be  more  protracted, 
lasting  some  weeks,  all  the  signs  being  less  pronounced  but  advancing 
to  a  terminal  coma. 


MENINGITIS.    SUBDURAL  ABSCESS  AND  SINUS  THROMBOSIS  623 

Diagnosis.  The  early  signs  are  closely  imitated  by  acute  otitis  media 
in  children,  while  in  adults  a  collection  of  pus  under  tension  outside  the 
dura  may  give  similar  signs.  On  lumbar  puncture  there  will  be  found  pus 
containing  polymorphonuclear  cells  and  organisms  if  meningitis  is  present, 
and  such  an  examination  will  also  distinguish  acute  cerebro-spinal  fever 
or  epidemic  cerebro-spinal  meningitis  by  revealing  the  presence  of  the 
diplococcus  meningitidis. 

Treatment.  Though  these  cases  are  hopeless  when  diffuse,  one  can 
seldom  be  certain  of  the  degree  to  which  the  infection  has  spread  ;  hence 
the  local  focus  of  origin  should  be  explored,  whether  this  is  a  depressed 
fracture  or  a  chronic  otitis,  when  free  opening  and  drainage  should  be 
arranged.     The  pain  may  be  relieved  by  morphia  if  the  condition  is  hopeless. 

(b)  Subdural  Abscess  and  Localized  Meningoencephalitis.  In  a  few 
cases,  especially  those  of  otitic  origin,  the  infection  may  remain  localized 
by  adhesions  between  the  dura  and  pia  mater.  The  signs  will  be  those  oi 
suppuration  under  tension,  viz.  fever  and  local  pain,  together  with  signs  of 
increased  intracranial  pressure,  headache,  vomiting,  possibly  focal  signs, 
and  later  coma,  when  the  abscess  bursts  into  the  ventricle  or  subdural 
space. 

Treatment.  Exploration  through  the  site  of  infection,  opening  the 
dura  (which  bulges,  does  not  pulsate,  and  is  altered  in  colour),  removing 
sloughs  of  pia-arachnoid  and  brain,  and  establishing  free  drainage  may  save 
some  cases. 

(c)  Infections  of  the  Intracranial  Sinuses  (Sinus  Thrombosis).  This  is  a 
very  grave  condition  because  the  infective  clots  are  easily  detached  and 
pass  into  the  circulation,  causing  septico-pysemia  with  abscess  in  the  lungs, 
joints,  subcutaneous  tissues,  &c.  This  is  not  only  the  case  when  the  sinuses 
are  obviously  thrombosed  and  filled  with  clot,  but  also  small  clots  on 
localized  necrotic  portions  of  a  sinus  are  just  as  dangerous,  and  prevention 
of  their  spread  into  the  circulation  by  surgical  interference  is  of  paramount 
importance. 

The  condition  may  arise  from  infected  wounds,  especially  depressed  and 
compound  fractures  of  the  skull,  infective  disease  of  the  scalp  or  orbit, 
e.g.  facial  carbuncle,  or  of  the  various  air-sinuses  of  the  skull  such  as  the 
sphenoidal,  frontal,  and  above  all  of  the  middle  ear  and  mastoid  antrum. 

The  essential  signs  are  repeated  rigors  and  the  advent  of  septico-pysemia, 
headache,  vomiting,  and  meningeal  irritation  being  also  noted.  The  longi- 
tudinal, cavernous,  and  lateral  sinuses  are  affected  in  this  manner  ;  the 
smaller  sinuses,  no  doubt,  are  also  affected,  but  can  hardly  be  diagnosed  as 
such. 

(1)  Infective  Thrombosis  of  the  Longitudinal  Sinus.  This  may  result 
from  infection  of  scalp- wounds  or  depressed  fractures  or  other  infective 
disease^  of  scalp  or  skull.  Except  that  the  frontal  veins  may  be  distended, 
the  condition  can  hardly  be  diagnosed  apart  from  the  presence  of  a  suppu- 
rating wound  in  the  neighbourhood,  when  the  onset  of  rigors,  fixed  headache, 
&c,  will  suggest  the  advisability  of  exploration  and  opening  the  skull  at 


A  TEXTBOOK  OF  SURGERY 

the  site  of  injury.  The  sinus  wall  will  be  found  necrotic  01  obviously 
thrombosed  and  impervious,  in  which  case  it  will  be  tied  at  each  end  beyond 
the  limits  of  the  clot  or  occluded  with  gauze  packed  between  the  sinus  and 
the  skull  and  then  opened,  clots  turned  out.  and  drainage  established. 

(_')  Infective  thrombosis  of  the  cavernous  sinus  may  arise  from  facial 
carbuncle,  inflammation  of  the  orbit,  upper  jaw.  sphenoidal  sinus,  or  by 
extension  from  the  Lateral  sinus  through  the  superior  petrosal  sinus. 

Signs.  Repeated  rigors  and  swinging  pyrexia  with  exophthalmos  and 
dilatation  of  the  orbital  veins  and  conjunctival  vessels,  involvement  of 
the  oculo-motor  nerve,  causing  ptosis,  squint,  or  complete  paralysis  of 
the  eyeball,  will  make  the  diagnosis  certain. 

Treatment.  There  is  nothing  to  be  done  for  these  cases  except  to  relieve 
pain  with  morphia. 

(3)  Infective  Thrombosis  of  the  Lateral  Sinus.  The  infection  spreads 
from  the  middle  ear  either  through  the  mastoid  into  the  posterior  fossa 
or  along  the  veins  which  drain  the  petrous  bone  into  the  sinus.  The 
thrombosis  starts  in  various  parts  of  the  sinus,  and  it  is  well  to  remember 
that  the  sinus  is  in  relation  to  the  mastoid  antrum,  not  only  behind  but 
also  below  and  on  its  inner  side,  and  that  thrombi  may  be  present  and 
passing  into  the  blood-stream  some  time  before  the  sinus  is  blocked  com- 
pletely, and  if  there  is  thrombosis  low  down  the  sinus  at  the  upper  part 
of  the  jugular  fossa  it  may  be  missed  on  inspection  through  the  ordinary 
mastoid  excavation  in  the  skull.  It  is  by  thorough  treatment  of  such  early 
cases  that  success  will  be  obtained,  as  where  the  condition  is  well  marked 
with  thrombosis  right  down  the  jugular  the  prognosis  is  always  very  grave. 

Signs.  Repeated  rigors  with  swinging  temperature,  rising  as  high  as 
105°  and  falling  below  normal ;  in  some  cases  the  pyrexia  is  continuous  with 
rigors.  These  rigors  are  danger-signals,  and  call  for  immediate  explora- 
tion of  the  mastoid  and  lateral  sinus  in  cases  where  there  has  been  otorrhcea 
for  some  while.  Repeated  vomiting,  headache,  and  pain  in  the  ear  are 
common,  while  optic  neuritis  is  by  no  means  unusual ;  meningeal  irritation 
and  retraction  of  the  head  point  to  infection  of  the  posterior  fossa  around 
the  sinus.  The  pulse  is  rapid.  Local  signs  are  inconstant ;  there  is  seldom 
tenderness  or  swelling  over  the  mastoid.  A  tender  swelling  along  the 
jugular  vein,  unless  extending  a  long  distance  down  the  neck,  is  incon- 
clusive, as  it  may  be  caused  by  enlarged  glands  or  v.  Bezold's  mastoiditis 
when  occurring  under  the  upper  part  of  the  sternomastoid.  As  the  infection 
becomes  generalized  it  may  assume  different  types,  as  : 

(a)  Pyaemia  with  infection  of  the  lungs,  rapid  respiration,  patchy  pneu- 
monia, abscess-formation  in  the  lung  (which  may  be  coughed  up  with 
successful  issue),  abscesses  in  joints,  &c. 

(6)  A  typhoid  condition  with  diarrhoea,  jaundice,  torpor. 

(c)  A  meningeal  type  with  head-retraction,  irritability,  stupor,  and  coma. 

Diagnosis.  This  turns  mainly  on  repeated  irregular  rigors  and  the 
presence  of  old-standing  otorrhcea  and  the  exclusion  of  such  conditions  as 
malaria,  intermittent  urinary  fever,  enteric,  and  other  forms  of  pyaemia. 


THROMBOSIS  OF  THE  LATERAL  SINUS 


625 


Treatment.  The  aim  of  surgical  intervention  is  to  block  the  sinus  above 
and  below  the  thrombus,  turn  out  septic  clots,  and  so  prevent  further  spread 
of  the  infection.  The  earlier  this  is  done  the  better  ;  hence  the  importance 
of  exploring  the  sinus  when  operating  on  the  mastoid  where  any  signs  of 
danger  are  present  such  as  headache,  irregular  fever,  and  above  all  rigors 
and  head-retraction,  and  if  there  be  found  grave  involvement  of  the  sinus 
wall  in  the  shape  of  acute  inflammation  or  necrosis  (patches  of  yellow,  grey, 
or  green)  to  obliterate  the  sinus  even 
though  pervious,  for  in  such  cases 
thrombosis  and  its  sequelae  will  surely 
follow  and  to  delay  is  simply  to  court 
disaster. 

Operation.  This  commences  as 
for  mastoidectomy.  Next,  by  enlarg- 
ing the  excavation  in  the  bone  back- 
wards the  sinus  is  exposed  freely,  and 
if  the  latter  be  found  firm  and  throm- 
bosed or  with  areas  of  acute  inflam- 
mation or  necrosis  in  its  wall  the  skull 
should  be  cut  away  towards  the  tor- 
cular  till  quite  healthy  sinus-wall  free 
from  clots  or  necrosis  is  found.  The 
sinus  is  then  obliterated  at  this  point 
by  inserting  a  plug  of  gauze  between 
the  skull  and  the  sinus.  It  is  no  use 
aspirating  the  sinus  to  test  its  permea  - 
bility,  for  it  may  be  quite  pervious,  containing  mostly  liquid  blood,  and  yet 
there  may  be  infective  parietal  clots  ready  to  pass  into  the  circulation.  Iu 
cases  where  there  is  no  evidence  of  necrosis  or  thrombosis  the  sinus  should  be 
followed  right  down  into  the  jugular  fossa,  removing  the  bone  over  this, 
before  deciding  that  it  is  normal,  and  in  doubtful  cases  where  there  are 
severe  repeated  rigors  or  other  evidence  of  pyaemia  it  will  probably  be  safer 
to  occlude  the  sinus  rather  than  miss  small  clots  in  the  jugular  sinus.  Next, 
having  occluded  the  upper  end  of  the  sinus,  the  wound  is  covered  with 
gauze,  the  side  of  the  neck  cleaned,  and  the  jugular  exposed  by  an  incision 
along  the  anterior  border  of  the  sternomastoid,  with  its  centre  opposite  the 
hyoid  bone.  If  there  is  evidently  thrombosis  lower  down,  the  vein  is  attacked 
at  a  lower  point,  even  right  down  at  the  clavicle. 

Having  retracted  the  sternomastoid,  the  vein  is  exposed  and  traced  down 
below  any  clot  or  inflamed  part,  when  it  is  divided  between  two  ligatures. 
The  lower  end  of  the  upper  part  of  the  vein  is  brought  out  through  the  skin, 
being  secured  there  with  a  suture  to  afford  exit  to  any  pus  in  the  upper 
part.  We  have  had  good  results  from  simply  tying  the  vein,  but  the  method 
described  is  safer.  The  wound  in  the  neck  is  closed  and  attention  directed 
again  to  the  wound  in  the  mastoid.  The  sinus  is  opened  and  clots  and 
necrosed  wall  removed,  the  cavity  washed  out  and  packed  with  gauze.  If 
i  40 


Fig.  243.  Treatment  of  infective  thrombosis 
of  the  lateral  sinus,  a,  Suppuration  spread- 
ing from  the  mastoid,  b,  Clot  in  the  lateral 
sinus,  c,  Ligature  of  the  jugular  below  the 
clot,  d,  Plug  compressing  the  sinus  above 
the  clot. 


626  A  TEXTBOOK  OF  SURGERY 

there  is  time  the  middle  ear  is  made  one  with  the  mastoid  by  cutting  away 
the  posterior  wall  of  the  bony  meatus  and  outer  wall  of  the  aditus  (mas- 
toidectomy) and  this  cavity  packed  with  a  second  strip  of  gauze.  The 
external  meatus  may  he  enlarged  and  the  conchal  flap  cut  at  this  operation 
or  later.  The  lateral  sinus  should  be  drained  through  the  partially  sutured 
iior  incision.  The  wound  is  dressed  daily,  removing  the  gauze  Erom 
the  inside  of  the  sinus  but  leaving  the  pack  between  the  skull  and  sinus 
lor  three  days:  irrigation  with  peroxide  lotion  and  other  antiseptics  will 
help  to  promote  a  clean  wound,  but  healing  will  take  some  time  ;  the  dura, 
if  sloughy,  may  give  way  and  a  fungus  hernia  cerebri  result  or  signs  of 
abscess  appear  in  joints,  lungs.  &c,  where  they  are  opened  as  found.  The 
mortality  of  this  condition  is  heavy,  but  early  explorations  on  doubtful  cases 
will  improve  results  in  the  future.  Failure,  after  occluding  the  sinus  and 
jugular,  may  be  due  to  spread  along  the  inferior  petrosal  sinus,  which  cannot 
be  reached,  or  through  small  sinuses  in  the  petrous  bone. 

(d)  Inflammations  of  the  Brain ;  Encephalitis,  Cerebral  and  Cerebellar 
Abscess.  "With  respect  to  origin,  cerebral  abscesses  may  be  divided  into 
three  groups  : 

(1)  Those  following  injuries  such  as  depressed  compound  fractures, 
infection  of  injured  brain-substance  or  clots  without  breach  of  the  surface, 
or  around  some  foreign  body  such  as  a  bullet. 

(2)  Those  following  spread  of  infection  from  neighbouring  parts  such  as 
the  frontal  and  sphenoidal  sinuses,  cranial  bones,  jaws,  and  above  all  the 
middle  ear  and  mastoid. 

(3)  As  metastases  from  distant  parts,  especially  the  lungs,  from  some 
chronic  suppurative  disease  such  as  bronchiectasis.  Similarly,  abscesses 
may  arise  in  conditions  of  general  infection  such  as  enteric  or  scarlet  fever, 
and  in  this  group  may  be  included  some  instances  of  tuberculous  abscess, 
which  is  always  secondary  to  some  other  focus  but  may.  however,  originate 
in  the  middle  ear. 

Anatomy.  Cerebral  abscesses  are  usually  single,  but  when  arising  in 
the  course  of  a  general  infection  may  be  multiple,  and  if  consecutive  to 
middle-ear  disease  there  may  be  one  abscess  in  the  cerebrum  and  another 
in  the  cerebellum.  Cerebral  abscesses  vary  much  in  their  acuteness  :  in 
some  instances  the  brain-substance  breaks  down  rapidly  and  there  is  little 
reaction  and  fibrosis  around  (encephalitis),  while  in  other  examples  the 
process  is  slow  and  there  may  be  a  well-defined  fibrous  capsule  around, 
the  abscess  being  distinctly  chronic.  The  latter  condition  is  especially 
found  in  abscesses  of  otitic  origin  ;  the  former  w^hen  due  to  some  injury. 
Since  abscesses  consecutive  to  middle-ear  disease  (otitic  abscesses)  are 
much  more  common  than  all  the  other  sorts  put  together,  a  detailed 
account  of  these  and  their  treatment  will  be  given,  and  then  a  few  points 
of  the  other  varieties  will  be  discussed. 

(1)  Otitic  Cerebral  Abscess.  The  condition  only  occurs  where  otitis 
media  has  been  present  at  least  a  year.  The  immediate  cause  of  the  spread 
of  infection  is  often  uncertain.     Damming  up  of  pus  by  growth  of  polypi, 


OTITIC  CEREBRAL  ABSCESS  627 

opening  up  of  lymphatic  channels  by  operative  interference  such  as  removal 
of  polypi  or  other  slight  injuries,  may  determine  the  tracking  of  infection 
through  the  cranium  and  meninges  to  the  brain.  The  infection  may  be 
direct  extension,  the  dura  being  glued  to  the  skull  and  the  pia  to  the  dura. 
resulting  in  the  formation  of  an  abscess  in  the  superficial  part  of  the  brain 
in  immediate  relation  to  the  meninges.  In  other  cases  the  spread  may  be 
along  veins  or  tissue-spaces,  there  being  no  adhesions  over  the  abscess, 
which  is  fairly  deep  in  the  substance  of  the  brain  with  apparently  normal 
brain-substance  between  the  abscess  and  the  surface  of  the  latter.  The 
infection  may  spread  upwards  from  the  middle  ear  through  the  tegmen 
tympani  to  the  temporo-sphenoidal  lobe  or  backwards  from  the  mastoid 
antrum  to  the  posterior  fossa  and  cerebellum.  Cerebellar  abscesses  are 
about  twice  as  common  as  those  of  the  temporo-sphenoidal  lobe.  Not 
infrequently  extradural  abscess,  meningitis,  or  sinus  thrombosis  may  occur 
together  with  cerebral  abscess,  complicating  the  diagnosis. 

Signs.  The  origin  is  often  obscure,  the  initial  stages  being  unnoticed 
or  mistaken  for  some  other  affection,  and  there  may  be  a  considerable  latent 
period  devoid  of  symptoms. 

(a)  Initial  signs  are  described  (Macewen),  consisting  of  headache,  cerebral 
vomiting,  fever,  sometimes  a  rigor  ;  the  pulse  is  rapid,  the  tongue  furred, 
appetite  is  lost,  constipation  marked,  and  the  otorrhoea  ceases  ;  the  stage 
lasts  two  or  three  days.  Such  signs  may,  however,  simply  point  to  extra- 
dural or  subdural  infection,  which  may  or  may  not  pass  on  to  cerebral  abscess. 
In  any  case,  however,  where  such  signs  appear  in  the  course  of  a  case  of 
otitis  media  the  indication  is  immediately  to  open  the  mastoid  antrum  and 
explore  the  middle  and  posterior  fossse  of  the  skull.  Possibly  by  so  doing 
we  prevent  the  formation  of  a  cerebral  abscess,  since  the  latent  period,  during 
which  the  abscess  develops,  is  of  some  weeks  or  months  duration,  (b)  When 
the  abscess  is  well  developed  the  signs  may  be  divided  into  general  and 
localizing. 

General  signs  are  due  to  raised  intracranial  pressure  and  infection. 
The  mental  state  becomes  sluggish,  the  patient  lying  quiet,  taking  no 
notice  nor  initiating  any  action  ;  if  questioned,  his  answers  are  intelligent 
but  given  after  some  delay.  Later  there  is  a  want  of  sustained  attention 
and  the  mind  becomes  more  obscured  and  stupor  advances,  passing  into 
final  coma. 

Headache  is  often  absent  or  diminished  from  that  of  the  initial  stage, 
but  in  some  cases  may  be  agonizing. 

Vomiting,  in  curious  contradistinction  to  cases  of  cerebral  tumour,  is 
seldom  found,  but  if  occurring  will  be  of  the  cerebral  variety. 

Constipation  is  marked,  and  a  foul  condition  of  the  tongue  and  mouth, 
with  sordes  on  the  teeth,  gives  rise  to  a  characteristic  odour,  noted  also 
in  typhoid  cases. 

The  pulse  is  slow — 40  to  50.  The  temperature  is  subnormal,  e.g.  97°, 
and  irregular,  but  both  pulse  and  temperature  will  be  raised  when  meningeal 
or  sinus  complications  are  present.     Muscular  weakness  is  great. 


A  TEXTBOOK  OF  SURGERY 

Wasting  is  a  marked  feature  in  a  case  of  any  Btanding  and  is  very  charac- 
teristic :  the  colour  of  the  skin  is  anaemic  and  earthy.  .V  "  cold  typhoid  " 
Btate  with  low  temperature  and  slow  pulse  should  at  once  suggest  cerebral 
abscess.  Optic  neuritis  is  fairly  often  present,  but  its  absence  is  of  little 
value  as  negative  evidence. 

Local  signs  will  vary  as  the  abscess  is  in  the  teniporo-sphenoidal  lobe  or 
the  cerebellum. 

(a)  Temporo-sphenoidal  Abscess.  "When  small  there  may  be  no  localizing 
signs,  though  on  exploring  the  mastoid  and  middle  ear  a  fistulous  opening 
through  the  tegmen  tympani  will  suggest  the  condition  and  shows  the 
importance  of  exploring  the  mastoid  first.  As  the  abscess  enlarges  it 
presses  in  different  directions — most  usually  on  the  oculomotor  nerve, 
causing  ptosis,  dilatation  of  the  pupil,  and  external  deviation  of  the  eyeball 
on  the  side  of  the  abscess.  Further  extension  may  press  on  the  face  centre, 
causing  facial  spasm  or  paralysis  on  the  opposite  side,  and  if  the  abscess  is 
on  the  left  side  motor  aphasia  (facial  paralysis  on  the  same  side  points  to 
involvement  of  the  facial  nerve  in  the  acpieduct  of  Fallopius,  and  is  of 
the  lower  segment  type).  Further  extension  may  cause  paralysis  of  the 
arm  or  leg  on  the  opposite  side.  Sensory  defects  are  less  easy  to  estimate 
owing  to  the  patient's  mental  condition,  but  pressure  on  the  occipital  pole 
will  cause  loss  of  the  opposite  half-field  of  vision.  To  sum  up,  the  oculo- 
motor palsy  is  the  only  localizing  sign  at  all  common,  and  the  size  of  the 
pupil  gives  a  rough  idea  of  that  of  the  abscess. 

(b)  Cerebellar  Abscess.    The  abscess  is  usually  found  in  the  lateral  lobe, 
and  the  localizing  signs  are  often  but  slight. 

In  the  general  signs  there  may  be  some  difference  from  cerebral  abscess, 
for  headache,  vomiting,  and  optic  neuritis  are  much  more  usual  in  cerebellar 
cases.  Very  great  weakness,  syllabic  speech,  yawning,  and  trismus  are 
found  in  cerebellar  cases  (Mace wen).  Weakness  of  the  arm  on  the  side  of 
the  lesion  and  increase  of  the  knee-jerk  on  that  side  will  sometimes  be  found. 
Signs  of  cerebellar  ataxy  may  give  valuable  clues  :  the  staggering  gait  and 
tendency  to  fall  to  the  opposite  side,  the  ataxy  of  the  arm  on  the  same 
side  (see  General  Diagnosis  of  Cerebral  Cases),  the  deviation  of  the  eyes 
to  the  opposite  side,  will  serve  to  locate  the  abscess ;  retraction  of  the 
head  and  a  small  weak  pulse  may  also  be  noted. 

(c)  Finally  a  terminal  stage  is  described,  due  to  bursting  of  the  chronic 
abscess  into  the  ventricles  or  rapid  spread  and  enlargement  of'  an  acute 
abscess.  In  this  condition  stupor  rapidly  passes  into  coma,  the  pulse 
becomes  small  and  very  rapid,  respiration  assumes  the  Cheyne-Stokes 
rhythm,  and  irregular  pyrexia  and  hyperpyrexia  occur.  The  livid  colour, 
deep  coma,  irregular  pulse,  loss  of  sphincter-control,  and  signs  of  pulmonary 
oedema  mark  the  swiftly  approaching  end. 

(2)  Cerebral  Abscesses  other  than  Otitic.  These  are  less  common, 
and  when  resulting  from  injuries  will  usually  be  of  an  acute  nature  and  akin 
to  meningo-encephalitis.  Headache,  fever,  rigors,  irritability,  vomiting, 
will  be  noted  ;    in  fact,  the  early  stage  of  cerebral  abscesses,  described  by 


DIAGNOSIS  OF  CEREBRAL  ABSCESS  629 

Macewexi,  fairly  rapidly  advancing  to  coma.  Owing  to  the  rapidity  of 
advance  there  is  no  time  for  the  typhoid  condition  to  develop.  In  other 
examples  the  abscess  may  be  of  the  chronic  variety  described  above,  especi- 
ally if  developing  around  a  bullet  which  has  not  been  removed. 

Signs.  The  general  signs  will  be  as  detailed  above.  Localizing  signs 
are,  in  the  first  place,  lesions  of  the  scalp  or  skull — bearing  in  mind,  how- 
ever, that  contre-coup  may  cause  laceration  of  the  brain  followed  by  abscess 
on  the  opposite  side  to  the  obvious  external  lesion,  and  therefore  if  fits, 
paralyses,  or  other  localizing  signs  are  noted  they  form  a  more  true  indica- 
tion of  locality  than  external  signs  on  the  skull. 

From  suppuration  of  the  frontal  sinus  cerebral  abscess  may  result, 
seldom  localized  by  focal  signs  but  by  examination  of  the  nose  and  accessory 
sinuses  (see  Surgery  of  the  Nose). 

Abscesses  resulting  as  metastases,  e.g.  from  the  lung,  can  only  be  located 
by  focal  signs,  and  these  may  not  develop  till  too  late  for  operation 
to  be  successful.  The  general  signs  are  as  in  a  cerebral  abscess  of  otitic 
origin. 

Diagnosis.  This  may  not  be  easy,  particularly  in  the  early  cases. 
Conditions  likely  to  be  confused  with  cerebral  abscess  are  various  typhoid 
states  such  as  that  found  in  enteric  fever,  but  also  in  some  of  the  intoxica- 
tions, as  uraemia,  diabetes,  cholsemia,  &c.  The  slow  pulse,  subnormal 
temperature,  absence  of  splenic  enlargement,  rose  spots,  and  Widal  reaction 
will  help  to  distinguish  uncomplicated  cases  from  enteric,  but  if  there  is 
in  addition  meningitis  or  sinus  thrombosis  the  matter  is  less  easy  and  shows 
the  importance  of  critical  examination  of  the  ears,  fundi,  eye-movements, 
pupils,  and  motor  functions  in  obscure  cases  of  a  typhoid  nature.  Examina- 
tion of  the  urine  and  discovering  low  specific-gravity  albumen  and  casts, 
or  sugar  may  clear  up  the  diagnosis  at  once.  From  meningeal  inflammation, 
whether  extra-  or  intradural,  the  more  acute  onset,  with  fever,  irritability, 
head-retraction,  photophobia,  and  spasms,  found  in  the  latter  condition, 
will  discriminate,  while  from  sinus  thrombosis  the  repeated  rigors  of  the 
latter  will  distinguish  ;  but  in  many  cases  of  otitic  origin  it  will  be  necessary 
to  explore  the  middle  ear,  antrum  and  cranial  fossae,  and,  having  dealt  with 
a  sinus  thrombosis  or  extradural  abscess,  to  wait  and  see  what  effect  this 
has  on  the  condition,  and  whether  it  all  clears  up  or  whether  the  signs  of 
cerebral  abscess  become  more  obvious  when  the  complication  has  been 
dealt  with. 

In  cases  of  traumatic  origin  the  condition  of  the  skull  and  scalp  will 
be  of  help  ;  nor  must  one  overlook  such  chronic  sources  of  infection  as 
bronchiectasis. 

From  cerebral  tumours  proper  the  infrequency  of  headache,  vomiting, 
and  optic  neuritis,  as  well  as  the  typhoid  state,  wasting,  constipation  and 
odour,  will  generally  discriminate. 

Treatment  of  Cerebral  Abscess.  This  consists  in  operating  as  soon 
as  diagnosis  is  made,  opening  and  draining  the  abscess.  The  route  taken 
varies  with  the  position  of  the  abscess. 


A  TEXTBOOK  OF  SURGERY 

(1)  Otitic  Abscesses.  These  abscesses  are  best  approached  through  a 
preliminary  opening  of  the  antrum,  middle  ear.  and  cranial  fossa?  (as  described 
under  Mastoidectomy),  Eot  in  a  good  many  eases  it  may  not  be  certain 
whether  the  ahscess  is  in  the  cerebrum  or  cerebellum,  and  finding  a  fistula 
leading  back  or  up  from  the  antrum  or  middle  ear  will  settle  which  fossa 
t«>  explore  first  if  there  be  any  doubt. 

Bulging  and  want  of  pulsation  of  the  dura  will  suggest  that  the  abscess 
lies  underneath.  The  skull  is  cut  away  with  gouge  and  rongeur  forceps 
till  the  dura  is  well  exposed  and  the  latter  is  slit  open  with  a  knife. 

The  brain  is  then  explored  by  thrusting  in  sinus  forceps  of  knife  in 
various  directions  ;  insertion  of  a  hollow  needle  is  of  little  use,  as  the  pus  is 
often  thick  and  the  needle  readily  blocked.  In  cases  where  the  abscess  is 
thick-walled  it  may  easily  be  felt  with  the  tip  of  the  sinus  forceps  as  they 
are  inserted,  and  if  the  wall  is  very  tough  it  will  be  advisable  to  use  a  sharp- 
pointed  knife  instead  of  the  blunter  instrument.  When  the  abscess  has 
been  found  the  opening  is  enlarged  and  pus  and  sloughs  extracted  by  gentle 
manipulations  and  a  fairly  wide  drain-tube  inserted  into  its  cavity  ;  the 
dura  and  skin  are  then  closed.  In  cases  of  double  otitis,  if  no  abscess  is 
found  on  the  most  likely  side  in  either  fossa,  the  operation  must  be  repeated 
on  the  opposite  side  before  giving  up.  As  a  rule,  then,  the  brain  will  be 
explored  through  the  opening  made  for  a  preliminary  mastoidectomy. 
To  reach  the  temporo-sphenoidal  lobe  the  skin-incision  is  carried  vertically 
upwards  for  two  inches  from  the  upper  part  of  the  mastoid  incision,  the  scalp 
reflected,  and  the  bone  of  the  tegmen  tympani,  tegmen  antri,  and  squamous 
part  of  the  temporal  bone  removed  with  gouge  and  rongeur  forceps,  which 
is  quicker  and  gives  better  drainage  than  trephining  an  inch  above  the 
auditory  meatus,  which  is  sometimes  given  as  the  landmark  for  exploring 
this  part  of  the  brain.  The  cerebellum  is  explored  by  making  a  horizontal 
incision  two  and  a  half  inches  back  from  the  mastoid  opening,  level  with  the 
-meatus  of  the  ear,  scraping  the  muscles  off  the  base  of  the  skull  (occipital  bone) 
and  penetrating  the  latter  about  two  inches  behind  the  meatus  and  half  an  inch 
below  Reid's  base-line,  i.e.  behind  the  occipito-mastoid  ridge.  The  opening  can 
usually  be  made  with  a  few  strokes  of  the  gouge  and  enlarged  wTith  rongeur 
forceps  till  of  sufficient  size  to  admit  of  satisfactory  exploration  ;  trephining 
is  seldom  needed  in  this  situation.  The  cerebellum  can  also  be  reached 
in  front  of  the  lateral  sinus  by  chiselling  through  the  inner  wall  of  the 
antrum,  and  it  is  worth  exploring  in  this  direction  if  the  abscess  is  not 
found  by  the  previous  method.  Drainage  is  carried  out  through  the 
enlarged  mastoid  incision,  and  if  the  outcome  is  successful  the  conchal 
flap  and  enlargement  of  the  meatus  may  be  carried  out  later. 

As  sometimes  more  than  one  abscess  occurs,  especially  in  the  cerebellum, 
recurrence  of  symptoms  a  few  days  after  a  successful  operation  indicates 
the  need  of  further  exploration. 

{'!)  Cerebral  abscesses  other  than  otitic  are  operated  on  similar  lines, 
opening  the  skull  in  accordance  with  localizing  signs,  but,  remembering  that 
these  focal  indications  may  be  due  to  pressure  of  an  abscess  in  a  neigh- 


HERNIA  CEREBRI 


631 


bouring  part  of  the  brain  (thus  a  temporo- sphenoidal  abscess  may  cause 
facial  or  upper-limb  paralysis),  it  will  be  needful  to  make  a  wide  removal 
of  skull  and  a  thorough  exploration  of  the  brain  in  order  not  to  miss  the 
'abscess.  Where  a  cerebral  abscess  is  secondary  to  suppuration  of  the 
frontal  sinus  it  may  be  reached  by  an  incision  similar  to  that  for  opening 
the  frontal  sinus  (see  Affections  of 
the  Nose)  along  the  eyebrow,  and 
after  opening  the  front  of  the  sinus, 
entering  the  cranium  through  its 
roof. 

After-treatment  consists  in  care- 
ful dressing  and  maintenance  of 
asepsis  and  drainage  till  the  abscess 
is  soundly  healed  :  the  tube  may 
be  removed  when  the  discharge  is 
serous. 

After  Results  of  Cerebral 
Injuries  and  Inflammation.  A 
number  of  important  affections 
arise  as  sequelae  to  damage  of  the 
brain  both  of  traumatic  and  in- 
flammatory nature,  some  of  which 
belong  also  to  the  physician  and 
neurologist,  but  demanding  surgi- 
cal attention,  either  because  sur- 
gical interference  may  in  some 
cases  be  indicated  or  because  they 
are  the  aftermath  of  conditions 
definitely  surgical. 

The  more  important  of  these 
sequela?  are'  (1)  hernia  cerebri, 
(2)  epilepsy,  (3)  traumatic  neuroses. 

(1)  Hernia  Cerebri.  This 
term  is  applied,  rather  unfortunately,  to  two  very  different  acquired 
conditions  of  protrusion  of  the  brain  through  an  aperture  in  the  skull, 
and  is  not  applied  to  congenital  protrusions  such  as  meningocceles  and 
encephalocoeles,  whereby  all  parallelism  with  abdominal  hernia?  is  lost. 
The  conditions  are  : 

(<i)  Hernia  cerebri  following  a  decompression  operation,  i.e.  a  wide 
removal  of  the  skull  made  by  the  surgeon  to  relieve  intracranial  pressure 
for  inoperable  cerebral  tumours,  the  brain  being  covered  wifrh  normal  skin, 
there  being  no  inflammation  or  suppuration.  In  such  cases  the  escape  of 
brain  through  a  wide  aperture  in  the  skull  relieves  pressure,  and  the  patient 
may  live  months  or  years  with  a  gradually  increasing  bulging  of  the  brain 
through  this  aperture,  but  free  of  headache,  vomiting  and  optic  neuritis, 
and  possibly  blindness. 


Fig.  244.  Fungating  hernia  cerebri  (fungus 
cerebri).  A,  The  granulating  brain  protrudes 
through  the  scalp  as  well  as  the  skull  and  dura. 
B,  Hernia  cerebri  caused  by  an  operation.  The 
skull  and  dura  are  opened  to  relieve  pressure, 
but  the  seal])  is  intact. 


632 


A  TEXTBOOK  OF  SURGERY 


(*>)  The  fungating  hernia  cerebri,  or,  as  it  may  well  be  called  on  analogy 
with  a  similar  condition  of  the  testis.  "  fungus  cerebri,"  is  the  result  of 
infective  encephalitis  with  destruction  of  the  overlying  cranium,  due  to 
infection  of  depressed  fracture  or  to  operations  to  relieve  some  intracranial 
infection,  such  as  cerebral  abscess  or  sinus  infection.  In  such  a  case  there 
is  a  pulsating,  red,  oedematous  mass  protruding  through  the  surface  of  the 
cranium  covered  with  lymph,  pus  and  sloughs,  and  consisting  of  a  mixture 

of  inflamed  brain  and  granula- 
tion tissue.  The  prognosis  is 
grave  :  usually  the  infection 
spreads  slowly  but  surely  along 
the  subdural  space  as  a  diffuse 
meningo-encephalitis,  with  fa- 
tal ending  after  some  days  or 
weeks.  Sometimes,  however, 
the  inflammation  clears  up  and 
the  oedematous  brain  retracts 
and  becomes  covered  with  scar- 
tissue.  (Fig.  245.) 

Treatment.  There  is  little 
to  be  done  except  to  maintain 
surgical  cleanliness  of  the  fung- 
ating tissues.  Removal  of  the 
fungus  is  useless,  only  opening 
up  more  tissue  spaces  and 
causing  spread  of  infection ; 
nor  should  pressure  be  exerted 
till  the  surface  is  clean  and 
nicely  granulating,  when  a 
well-fitting  cap  of  gutta-percha 
over  the  dressing*  will  prevent 
further  protrusion.  If  there  is 
reason  to  suspect  that  there  is 
an  underlying  abscess  main- 
taining excessive  intracranial  tension  exploration  is  reasonable,  but  if 
the  fungus  becomes  clean  it  will  very  possibly  become  healed  over  and 
covered  with  epidermis  or  retract  into  place.  Painting  with  alcohol  is 
advised,  but  this  only  acts  by  promoting  asepsis  ;  therefore  iodine  in  spirit 
may  be  used  as  being  more  efficacious. 

(2)  Epilepsy.  The  main  consideration  for  the  surgeon  is  whether  there  is 
a  gross  lesion  causing  the  fits  or  whether  the  case  belongs  to  the  "  idiopathic  " 
variety,  where  no  macroscopic  lesion  is  present.  As  regards  the  idiopathic 
variety,  it  is  generally  agreed  that  operations  on  the  skull  are  useless,  though 
it  has  been  claimed  (Alexander)  that  there  is  oedema  of  the  pia-arachnoid 
in  these  cases  and  that  opening  the  dura  over  this  in  several  places  causes 
relief  of  symptoms.     Where  there  is  a  macroscopic  lesion  it  may  be  : 


FlG.  245.  Fungus  hernia  cerebri  which  has  become 
healed  and  covered  with  epithelium,  three  years 
after  operation  for  extensive  disease  of  the  mas- 
toid antrum  with  thrombosis  of  the  lateral  sinus 
and  sloughing  of  the  dura  mater. 


EPILEPSY.    TRAUMATIC  NEUROSES  633 

(a)  Of  congenital  origin,  often  due  to  a  lesion  at  birth. 

(b)  Due  to  injury  later  in  life. 

(c)  Due  to  disease,  viz.  abscess  or  growth  (discussed  elsewhere). 

The  lesions  may  affect  the  skull,  meninges,  or  brain  ;  it  is  doubtful  if  a 
mere  scalp  lesion  alone  will  cause  epilepsy.  The  signs  are  twitchings  or  fits, 
which  may  be  generalized,  but  more  often  start  locally  and  remain  so  or 
spread  generally  (Jacksonian  epilepsy). 

The  diagnosis  is  made  on  the  history,  duration,  site  of  cranial  lesion, 
and  focal  signs. 

Prognosis  from  Operative  Treatment.  In  this  class  of  case  it  must  be 
admitted  that  prevention  is  far  better  than  cure.  In  other  words,  careful 
treatment  and  readiness  to  trephine  in  cases  of  depressed  fracture,  &c,  will 
in  many  instances  prevent  the  occurrence  of  epilepsy  later,  as  the  results  of 
operating  when  epilepsy  is  well  established  are  not  satisfactory,  especially 
if  some  time  has  elapsed  since  the  initial  lesion.  After  two  years  the  pros- 
pects are  distinctly  poor. 

Operative  Treatment  (this  refers  to  the  cases  arising  from  injury).  The 
skull  is  opened  freely,  usually  by  making  an  osteoplastic  flap  over  the  site 
of  the  centre  where  the  fits  take  origin.  Various  conditions  may  be  found, 
such  as  depressed  fracture,  excessive  callus,  spicules  of  bone  projecting  into 
the  brain,  necrosis  and  sequestra,  thickening  of  the  meninges,  adhesions 
of  the  brain  to  the  latter,  or  scars  of  the  brain. 

Lesions  of  the  skull  are  treated  by  free  resection  and  depressed  fragments 
are  removed  ;  thickened  meninges  are  cut  away.  The  cortex  should  not 
be  excised  as  the  resulting  scar  will  cause  more  fits,  though  there  may  be 
temporary  relief  before  the  scar  forms  again.  The  brain  should  be  freed 
from  adherent  meninges  and  a  strip  of  gold-foil  inserted  to  prevent  these 
from  forming  again,  since  such  "  anchoring  "  of  the  brain  is  a  definite  cause 
of  fits.  Old  clots,  arachnoid  cysts,  &c,  should  be  removed  with  as  little 
damage  to  the  underlying  brain  as  possible.  The  treatment  of  abscess  and 
tumour  is  discussed  elsewhere.  In  the  congenital  type,  if  operation  be 
done  early  it  may  be  successful. 

(3)  Traumatic  Neuroses.  These  may  follow  injuries  to  the  brain, 
but  are  not  uncommon  after  injuries  to  any  part  of  the  body,  especially  the 
back.  In  most  cases,  however,  there  has  been  a  general  shaking  up  of  the 
patient,  such  as  happens  in  falls,  and  railway  accidents,  from  which  the 
term  "  railway  spine  "  (Erichsen)  was  derived. 

As  regards  causation,  these  pathological  states  of  mind,  as  they  must  be 
considered,  may  arise  shortly  after  injury  or  not  for  some  time  ;  nor  need  the 
injury  be  severe.  Thus  we  have  seen  a  serious  case  of  hysterical  anaesthesia 
with  mental  degeneration  arise  from  an  extensive  but  quite  superficial  incised 
wound  of  the  forearm.  Predisposing  causes  are  inferior  physical  and  psychical 
development,  or  congenital  and  racial  degeneracy  due  to  alcohol,  tobacco, 
generally  bad  hygienic  surroundings,  &c,  or  emotional  disturbance  at  the 
time  of  injury.  But  all  these  accessories  may  be  wanting.  The  conditions 
arising  may  be  neurasthenic,  hysterical,  or  a  combination  of  these. 


634  A  TEXTBOOK  OF  SURGERY 

(a)  Traumatic  Neurasthenia.  The  symptoms  are  headache  (aggravated 
l>v  effort),  pain  in  the  back,  insomnia,  restlessness  and  irritability,  limited 

power  of  attention  and  failure  of  memory,  loss  of  visual  accommodation 
for  near  objects,  moroseness,  pessimism,  and  the  various  "  phobias,"  such 
as  fear  of  being  in  a  crowd  or  of  being  alone.  The  bulk  of  the  signs  are 
subjective. 

Objectively.  The  patient  looks  dejected  and  stupid,  stoops  and  slouches 
sluggishly  about  :  the  pulse  is  rapid,  the  pupils  dilated,  rarely  irregular  ; 
flushing  and  sweats  are  common  ;  the  spine  is  tender,  especially  in  the 
lower  part. 

Varying  degrees  of  this  condition  are  met  with  after  concussion  and 
laceration  of  the  brain  if  the  patient  be  not  allowed  to  rest  sufficiently  long, 
also  from  spinal  injuries. 

(b)  Hysteria  of  Traumatic  Origin.  Tremor  is  often  marked,  notably  of 
the  closed  eyelids. 

Areas  of  anaesthesia,  analgesia,  or  hyperesthesia  are  found  corresponding 
to  no  nerve  or  spinal  cord  segmental  distribution,  but  assuming  in  the  case 
of  the  limbs  a  glove  or  stocking  distribution,  or  perhaps  of  half  the  body. 
Anaesthesia  of  the  palate  is  characteristic.  Contraction  of  the  visual  fields 
may  be  found  as  well  as  alteration  of  colour  fields,  the  blue  field  becoming 
smaller  than  the  red.  Macropsia  and  micropsia  are  found,  i.e.  mistaking 
large  objects  for  small  and  vice  versa,  e.g.  sixpence  or  half  a  crown,  and 
weakness  of  accommodation,  sometimes  dyspnoea,  or  rather  tachypncea — 
the  latter  common  in  Hebrews. 

Fits  may  occur  of  varying  severity,  sometimes  assuming  the  magnitude 
of  epilepsy  but  more  commonly  distinguished  by  their  protracted  nature 
and  by  the  fact  that  the  patient  does  not  injure  herself,  bite  the  tongue,  or 
lose  control  of  the  sphincters.  Contractures  of  joints,  especially  the  hip, 
may  also  occur. 

Commonly  the  condition  met  with  is  chiefly  neurasthenic,  with  perhaps 
some  minor  hysterical  manifestation  such  as  glove-anaesthesia.  The  bad 
effect  of  litigation  on  these  cases  has  long  been  recognized,  and  increased 
legislation  does  not  make  treatment  any  more  easy. 

Treatment  consists  of  rest,  good  feeding,  open-air  life,  mild  exercise 
according  to  the  physical  condition  of  the  patient,  and  above  all,  abolition 
of  mental  worry  by  finishing  the  question  of  damages  and  compensation 
as  soon  as  possible,  but  as  the  latter  depends  on  the  prognosis  settlement 
is  not  easy. 

Prognosis  must  always  be  guarded.  Recovery  may  take  place  after  as 
long  as  five  years,  and  is  more  likely  in  the  slighter  cases.  Loss  of  memory, 
mental  depression,  and  emaciation  are  bad  signs  ;  some  of  such  cases  drift 
on  into  permanent  mental  weakness  and  even  insanity.  The  above  applies 
to  the  neurasthenic  part  of  the  syndrome;  the  hysterical  manifestations 
may  be  hard  to  manage,  and  only  by  persuading  the  patient,  often  a  difficult 
matter,  that  the  areas  of  anaesthesia,  contractures,  &c,  are  of  purely  imagi- 
nary origin. 


CEREBRAL  TUMOURS  635 

Cerebral  Tumours  and  other  Conditions  producing  Chronic 
Increase  of  Intracranial  Tension.  The  surgery  of  cerebral  tumours 
has  proved,  on  the  whole,  rather  disappointing,  in  spite  of  the  brilliant 
progress  in  diagnosis  and  the  remarkably  successful  issue  of  operations  in 
a  limited  number  of  cases.  This  depends  on  two  factors  :  first,  the  ten- 
dency of  most  growths  of  the  cerebrum  to  be  diffuse,  so  that  complete 
removal  is  hardly  possible  ;  second,  that  the  deeper  and  basal  parts  of 
the  brain  are  very  often  affected,  rendering  operative  interference  of  con- 
siderable danger  to  the  integrity  of  the  cerebral  functions. 

Varieties.  Tuberculous  nodes  are  the  commonest  tumours,  forming 
nearly  half  of  all  cases  ;  the  next  largest  group  are  gliomas  and  sarcomas, 
which  have  much  in  common,  being  sometimes  encapsuled  but,  unfor- 
tunately, more  often  diffuse,  and  occurring  in  about  30  per  cent,  of  all 
cases  :  gummata,  cysts  and  secondary  cancerous  nodes  form  only  about 
5  per  cent,  of  the  cases. 

Signs.  The  classic  signs  of  cerebral  tumour  are  headache,  vomiting 
and  optic  neuritis,  due  to  slowly  increasing  intracranial  pressure. 

The  headache  is  paroxysmal  and  often  of  great  severity. 

Vomiting  is  of  the  cerebral  type,  having  no  relation  to  food  and  not 
preceded  by  nausea. 

Optic  neuritis  is  known  by  puffy  swelling  of  the  optic  disc,  engorgement 
of  the  veins,  kinking  or  apparent  interruption  of  the  vessels  at  the  edge 
of  the  swollen  discs,  and  retinal  haemorrhages ;  this  is  to  be  distinguished 
in  early  cases  from  an  abnormal  appearance  of  the  disc  due  to  errors  of 
refraction. 

In  a  certain  number  of  cases  there  will  be  no  other  signs  except  wasting, 
and  ultimately  stupor  and  coma  come  on  without  the  tumour  being  localized 
by  signs.  Localizing  signs  are  similar  to  focal  signs  due  to  other  forms  of 
cerebral  disease,  and  may  be  dismissed  shortly. 

(1)  Motor  Effects.  When  originating  in  the  cortex  of  the  motor  area, 
typical  fits  of  the  Jacksonian  type,  commencing  in  some  definite  part 
(thumb,  face,  &c),  followed  by  paralysis,  spreading  in  definite  sequence, 
in  accordance  with  the  arrangement  of  the  cortical  areas,  viz.  from  leg  to 
arm  and  then  to  the  face  or  vice  versa.  If  the  tumour  is  subcortical  there 
will  be  spreading  paralysis  without  fits  and  sensory  changes,  while  if  the 
internal  capsule  is  invaded  the  paralysis  will  advance  more  rapidly  :  it 
should  be  noted  that  the  focal  effects  may  be  due  to  a  tumour  situated  in  a 
neighbouring  non-motor  area. 

(2)  Sensory  Effects.  Occurrence  of  hemianopia  in  occipital,  bitemporal 
blindness  in  pituitary  tumour  and  aphasia  (visual,  auditory,  motor)  have 
been  already  mentioned. 

(3)  Disturbance  in  equilibration  and  cerebellar  functions. 

(4)  Localized  swelling  and  tenderness  of  the  skull  from  invasion  by  tuber- 
culous deposits  or  sarcoma. 

(•"))  Radiographs  will  show  enlargement  of  the  sella  turcica  in  the  case 
of  pituitary  tumours. 


A  TEXTBOOK  OF  SURGERY 

(6)  Of  general  Bigns  helping  to  localize  the  tumour  are  gigantism  or 
acromegaly  in  cases  of  pituitary  tumour. 

/'  jnosis.  The  presence  of  the  three  classic  signs,  headache,  vomiting 
and  optic  neuritis,  render  diagnosis  easy  when  the  tumour  is  advanced, 
but  it  must  not  be  forgotten  that  the  same  signs  occur  in  uraemia  ;  an 
examination  of  the  renal  and  cardio-vascular  systems  will  exclude  this 
error. 

A  chronic  cerebellar  abscess  (unlike  that  occurring  in  the  temporo- 
Bphenoida]  lobe)  will  often  present  symptoms  very  like  those  of  tumour, 
but  the  presence  of  an  old-standing  otitis  media  forms  a  useful  clue. 

Treatment.  Gummata,  if  not  too  far  advanced,  will  yield  to  specific 
treatment,  and  tuberculous  nodes  may  fibrose,  calcify,  and  become  obsolete, 
but  all  other  tumours  will  progress  to  a  fatal  issue.  Moreover,  even  if  a 
tuberculous  tumour  heals,  the  increase  of  intracranial  pressure  while  this 
is  taking  place  may  lead  to  severe  optic  neuritis,  followed  by  secondary 
atrophy,  unless  the  skull  is  opened  and  the  pressure  mitigated.  Therefore, 
if  the  symptoms  do  not  yield  after  a  few  days  to  antisyphilitic  treatment, 
or  if  very  severe  so  that  terminal  coma  is  likely  to  supervene  shortly,  opera- 
tive treatment  is  urgently  indicated,  and  the  sooner  the  intracranial  pressure 
is  reduced  the  less  will  be  the  resulting  damage  to  the  cranial  contents. 
The  aim  of  operative  measures  is  either  :  (a)  palliative  (decompression), 
by  removal  of  a  large  area  of  skull  and  opening  the  dura  ;  or  (b)  radical, 
with  removal  of  the  tumour. 

The  results  of  exploration  showT  that  only  about  6  to  10  per  cent,  of 
these  cases  are  suitable  for  removal  of  the  growth.  The  following  are  contra- 
indications : 

(a)  If  the  tumour  is  very  deep,  in  the  basal  ganglia. 

(b)  If  there  are  several  tumours. 

(c)  If  the  tumour  is  infiltrating  (as  is  often  the  case  with  gliomas)  and  it 
is  uncertain  where  the  tumour  ends. 

(d)  If  secondary  to  cancer  elsewhere  (all  obscure  places  where  primary 
growths  may  occur  should  be  examined). 

(e)  If  very  large. 

(f)  Tuberculous  nodes  are  as  a  rule  unsuitable,  as  interference  with 
them  is  likely  to  cause  dissemination  and  set  up  tuberculous  meningitis. 

The  following  cases  are  favourable  to  removal  :  Gummata,  if  resisting 
iodides  and  mercury  after  six  weeks,  or  before  this  if  signs  of  pressure  are 
severe.  Cysts  following  injury  are  very  suitable  cases,  and  resemble  in 
pathology  those  already  described  as  occurring  in  the  arachnoid.  Cere- 
bellar cysts  in  children  are  suitable.  Hydatids  can  be  readily  removed. 
also  occur  in  new  growths,  when  the  outlook  is  poor  except  in  the 
of  pituitary  tumours.  Well-defined  and  encapsuled  gliomas  are 
suitable.  In  most  instances,  then,  operative  cure  is  unlikely,  but  as 
the  condition  of  the  tumour  can  seldom  be  foretold  before  the  skull  is 
opened,  and  as  such  opening  will  afford  great  relief  when  the  symptoms  are 
painful  and  distressing  as  well  as  prolong  life  by  diminishing  the  intra- 


OPERATIONS  FOR  CEREBRAL  TUMOURS  637 

cranial  pressure,  there  will  be  no  hesitation  in  exploring  such  cases  as  soon 
as  diagnosis  is  made,  if  not  relieved  by  antisyphilitic  measures. 

Operation  for  Cerebral  Tumours.  A  large  flap  of  scalp  and  skull 
at  least  four  inches  square  should  be  turned  down  by  one  of  the  methods 
mentioned,  for  choice  by  boring  holes  with  a  Doyen  drill  and  connecting 
these  with  punch-forceps  except  at  one  small  part  opposite  the  base,  where 
a  Gigli  saw  is  used,  bevelling  the  bone  flap  so  that  it  will,  when  replaced, 
not  press  on  the  brain.  The  site  of  the  opening  is  determined  by  the  focal 
signs  or,  failing  these,  in  the  temporal  region,  and  must  give  a  free  exposure 
so  that  the  brain  can  be  readily  palpated  with  the  finger,  since  focal  signs 
may  be  due  to  a  tumour  of  a  neighbouring  non-focal  part  of  the  brain,  and 
also  that  the  brain  on  expanding  be  not  crushed  against  the  edge  of  the 
aperture,  as  will  happen  where  only  a  small  hole  is  made.  Morphia  and 
chloroform  anaesthesia  is  advisable  to  diminish  cerebral  congestion.  Un- 
less the  condition  be  very  urgent  the  flap  is  replaced  for  a  week,  though  if 
there  is  no  shock  and  the  patient's  condition  is  good  the  operation  may 
proceed.  The  wound  is  reopened  after  about  a  week  unless  urgent  symptoms 
arise,  and  a  flap  of  dura  cut  of  rather  smaller  size  than  the  skull-flap  to  allow 
of  suturing,  the  meningeal  vessels  being  tied  as  divided.  The  tumour  may 
be  obvious  on  the  cortex  as  a  cyst  or  well-defined  swelling,  or  there  may 
be  no  indication  to  the  eye,  in  which  case  the  brain  is  carefully  palpated, 
and  if  the  aperture  has  been  made  sufficiently  large  there  will  be  a  good 
prospect  of  feeling  the  growth.  The  advisability  of  attempting  removal 
must  now  be  considered,  for  if  it  be  decided  that  removal  will  not  be  satis- 
factory the  flap  of  scalp  is  replaced,  either  removing  the  bone  from  it  or 
closing  with  expanding  wire  sutures  to  admit  of  expansion  of  the  brain 
(Hudson).     The  dura  should  be  at  most  only  partially  closed. 

As  regards  removal,  cortical  cysts  and  well-defined  tumours  of  the 
cortex  should  be  dissected  out ;  where  a  small  tumour  is  felt  in  the  substance 
of  the  brain  attempts  should  be  made  to  remove  it  by  blunt  dissection  after 
incising  the  brain  over  it.  Where  the  tumour  cannot  be  felt  with  the  finger 
the  brain  may  be  incised  in  the  place  indicated  by  the  focal  signs  and  deep 
palpation  made  with  the  finger,  though  this  is  a  risky  procedure.  After 
removal  of  the  tumour  bleeding  is  checked  by  temporary  packing  of  adrenalin- 
gauze  or  undersewing  and  ligaturing  bleeding-points.  The  dura  is  closed  and 
the  bone  flap  replaced,  with  drainage  down  the  dura  for  twenty-four  hours. 

Even  where  removal  is  incomplete  the  patient  may  recover  and  survive 
in  comfort  for  a  considerable  time. 

Operation  for  Cerebellar  Tumours.  To  explore  the  cerebellum,  a 
flap  having  its  base  at  the  mastoid  processes  and  its  free  end  half  an  inch 
above  the  inion  is  turned  back,  the  muscles  separated  from  the  bone,  and 
the  part  of  the  occipital  bone  underneath  removed  with  trephine  and 
rongeur-forceps  to  within  a  quarter  of  an  inch  of  the  foramen  magnum. 
The  dura  is  raised  as  a  flap  and  exploration  performed  as  before.  For 
inoperable  cases  where  decompression  is  practised,  it  will  be  good  to  remove 
the  bone  right  into  the  foramen  magnum,  forming  thus  a  very  wide  aperture. 


638  A  TEXTBOOK  OF  SURGERY 

Operations  for  Pituitary  Tumours.  Many  routes  have  been  employed 
for  reaching  this  deep-seated  body.  The  general  trend  of  opinion  is  that 
the  attack  should  be  made  through  the  nose,  and  many  plans  have  been 
employed.  In  any  case  the  anterior  part  of  the  sphenoidal  sinus  must 
be  opened,  and  probably  the  intraseptal  method  of  Killian-Hirsch  is  as 
good  as  any  :  the  septum  should  be  removed  in  the  submucous  manner  till 
the  sphenoid  is  reached,  when  the  anterior  wall  of  the  sinus  is  cut  away 
and  then  the  roof  divided,  the  tumour  being  removed  with  a  sharp  spoon. 
The  temporal  and  frontal  routes  have  also  been  successful.  The  tumours 
are  cystic  and  appear  often  microscopically  malignant,  but  recurrence  is 
long  delayed  and  relief  of  symptoms — headache,  acromegaly,  bitemporal 
blindness,  &c. —  often  considerable. 

Hydrocephalus.  In  this  affection  there  is  a  collection  of  fluid  in  the 
ventricles  of  the  brain,  causing  their  distension  and  also  expansion  of  the 
cranium.  The  cranium  becomes  abnormally  large  in  relation  to  the  face, 
the  sutures  in  young  subjects  yield,  and  fluctuation  of  the  skull  may  be 
noted  as  well  as  translucency.  The  bones  are  much  thinned  and  the  bulging 
downward  of  the  orbital  plates  causes  a  downward  protrusion  of  the  eyes, 
giving  a  curious  expression  of  pathos.  The  condition  may  be  congenital  or 
acquired.  Congenital  cases  are  often  associated  with  spina  bifida,  some- 
times following  operations  for  the  latter  condition  owing  to  upsetting  of 
the  drainage  of  the  cerebro-spinal  fluid.  Acquired  cases  follow  acute  or 
syphilitic  meningitis  by  compression  of  the  veins  of  Galen,  or  blocking  of  the 
iter  a  tertio  ad  quartum  ventriculum  or  the  foramen  of  Majendie  by  tumours 
of  the  third  ventricle,  &c.  In  addition  to  the  swelling  of  the  cranium  there 
may  be  headache,  fits,  blindness,  dementia,  ending  in  coma  and  death, 
but  these  patients  may  live  many  years  or  arrest  of  the  condition  may 
take  place  its  advance  ceasing. 

Since  the  discovery  that  cerebro-spinal  fluid  drains  into  the  venous 
sinuses  from  the  subdural  space,  when  the  tension  there  is  raised  (Hill), 
various  methods  have  been  used  to  drain  the  ventricles  into  this  space. 
The  ventricles  have  been  drained  into  the  subdural  space  by  opening  the 
skull  close  to  the  anterior  fontanelle,  opening  the  dura,  and  pushing  some 
strands  of  silk  through  into  the  ventricle,  the  outer  part  of  the  threads 
lying  under  the  dura  (Cheyne),  or  a  rubber  tube  lubricated  with  vaseline 
may  be  employed.  The  brain  has  been  found  to  shrink  by  these  methods, 
but  the  patients  seldom  survive  any  length  of  time.  However,  as  the 
subdural  space  is  fairly  often  in  communication  with  the  ventricle  in  these 
cases,  it  will  be  better  to  drain  the  ventricles  into  one  of  the  veins,  e.g.  the 
jugular,  or  into  the  peritoneum,  either  by  a  fine  rubber  tube  or  wire  cable 
passing  down  the  neck,  over  the  clavicle,  and  so  to  the  abdominal  cavity, 
or  by  inserting  a  silver  tube  between  the  peritoneum  and  the  interior  of  the 
spinal  theca  through  the  body  of  a  lumbar  vertebra  (Cushing).  Ligature 
of  the  internal  carotids  in  order  to  limit  the  secretion  of  fluid  by  the  choroid 
plexuses  (Stiles)  is  said  to  have  met  with  some  success. 
Thus  the  field  for  surgical  endeavour  is  still  open. 


THE  SPINAL  CORD  639 

AFFECTIONS  OF  THE  SPINAL  CORD 

(Including  Fractures  of  the  Spine) 

In  this  section  are  considered  injuries  and  surgical  diseases  of  the  cord, 
while  only  those  affections  of  its  covering,  the  spinal  column,  are  considered 
which  are  usually  associated  with  damage  to  the  cord  itself.  Affections  of 
the  bony  covering,  which  are  but  rarely  associated  with  affections  of  the 
cord,  are  discussed  in  the  previous  section  on  the  Surgery  of  the  Skeleto- 
motor  System  (pp.  433-145). 

Anatomy.  Like  the  brain,  the  spinal  cord  consists  of  a  tube  of  nervous 
tissue  covered  by  three  layers  of  meninges,  the  whole  enclosed  in  a  flexible 
bony  covering  ;  but  the  arrangement  differs  considerably  in  detail.  The 
bony  covering  consists  of  many  vertebras  articulating  to  form  a  flexible  whole 
with  buffers  formed  by  the  intervertebral  discs,  which  help  to  prevent  shock, 
and  as  the  cord  is  in  the  centre  between  the  bodies  and  the  laminae,  it  is 
but  little  affected  by  movements  of  the  column.  The  dura  mater  of  the 
cord  is  separated  by  a  considerable  interval  from  the  walls  of  the  vertebral 
cavity,  the  space  being  filled  with  fat  in  which  the  cord  is  slung  by  the  nerve- 
roots,  the  continuity  of  the  spinal  with  the  cranial  dura,  and  the  ligamentum 
denticulatum  between  the  dura  and  pia  mater  at  the  sides.  The  latter 
bridges  across  the  tolerably  wide  gap  between  the  closely  fitting  pia  and 
the  loose  dura.  Thus  loosely  fitting  in  its  coverings,  the  cord  is  not  likely 
to  be  easily  affected  by  shocks  nor  compressed  by  effusion  or  growth  in 
the  canal  unless  the  space  is  considerably  diminished.  On  the  other  hand, 
the  cavity  and  the  cord  being  relatively  small,  once  there  is  sufficient  diminu- 
tion of  the  space  to  cause  pressure  on  the  cord  the  latter  will  suffer  severely 
and  very  likely  irrevocably.  The  cord  ends  at  the  lower  border  of  the  first 
lumbar  vertebra,  the  lower  part  of  the  spinal  canal  containing  the  cauda 
equina  in  its  dural  sheath.  This  is  important  for  performing  lumbar  punc- 
ture and  where  fractures  of  the  lumbar  vertebra  occur,  as  then  the  affection 
is  not  of  the  cord  but  of  peripheral  nerves,  and  the  prospects  are  very 
different. 

The  cord  consists  of  conducting  tracts  both  motor  and  sensory,  as  well 
as  reflex  nuclei  of  ganglionic  cells,  and  serves  to  conduct  impulses  from 
the  higher  centres  of  the  brain  and  medulla  as  well  as  for  the  origination  of 
reflex  actions. 

The  osseous  spine  consists  of  two  rigid  portions — the  sacrum,  which  is 
completely  rigid  ;  the  thoracic  spine,  which  is  only  relatively  fixed,  and  two 
flexible  parts,  the  cervical  and  lumbar,  and  it  is  at  the  junction  of  the  flexible 
with  the  more  rigid  portions  that  severe  injuries  are  likely  to  take  place. 

General  Diagnosis  of  Affections  of  the  Spinal  Cord.  The  reader 
is  referred  to  works  on  medicine  and  neurology  for  a  full  account  of  these 
conditions,  but  a  brief  account  of  the  more  salient  points  will  be  of  assistance. 
The  next  section  on  Peripheral  Nerves,  should  be  studied  at  the  same 
time  (p.  654). 


640  A  TEXTBOOK  OF  SURGERY 

(1)  Motor  Affections.  Both  upper-  and  lower-segment  lesions  are 
found  in  the  cord. 

(<i)  Upper-segment  Lesions.  Where  the  motor  cells  of  the  anterior  horn 
are  cut  oft  from  their  controlling  cells  in  the  cortex  cerebri  we  find  a  paralysis 
of  the  spastic  type  usually  affecting  a  large  group  of  muscles,  e.g.  one  or 
more  limbs.  The  affected  muscles  waste  but  slowly,  become  rigid,  and 
their  tendon  reflexes  are  increased  ;  sometimes  spontaneous  movements 
occur  (athetosis).  There  is  no  reaction  of  degeneration  in  these  muscles 
(by  this  reaction  is  meant  that  the  muscles  cease  to  respond  to  the  induced 
current,  and  when  stimulated  by  the  make  or  break  of  the  constant  current, 
instead  of  giving  a  short  sharp  twitch,  give  a  prolonged  sluggish  contraction). 

(b)  Lower-segment  Lesions.  Where  the  anterior  horn  cells  of  the  cord 
(motor  cells  of  the  lower  segment)  or  the  nerve-fibres  arising  from  these 
are  affected  there  will  be  a  flaccid  paralysis  of  the  muscles  supplied ;  the 
tendon  reflex  is  absent  or  sluggish,  the  muscles  waste  rapidly,  and  the 
reaction  of  degeneration  is  well  marked  :  anterior  poliomyelitis  of  infants 
is  a  good  example  of  this.  The  grouping  of  the  muscles  affected  in  lower- 
segment  lesions  usually  differs  from  that  found  in  upper-segment  lesions. 
Usually  the  paralysis  affects  fewer  muscles,  and  the  groups  are  those  supplied 
by  a  certain  segment  or  segments  of  the  cord,  in  this  way  differing  from 
lower-segment  lesions  arising  from  affections  of  peripheral  nerves.  For 
example,  in  spiral  paralysis  of  the  anterior  tibial  muscles  the  tibialis  anticus 
often  escapes,  being  supplied  from  the  fourth  lumbar  segment,  while  the 
peronei  and  other  extensors  of  the  toes  are  supplied  by  the  fifth  lumbar 
motor  nucleus,  which  is  perhaps  alone  affected.  Should  the  external  popliteal 
nerve  be  affected  the  tibialis  anticus  will  be  affected,  as  well  as  the  rest 
of  the  anterior  tibial  group. 

(2)  Sensory  Affections.  The  peripheral  nerves  convey  at  least  three 
kinds  of  sensation  in  three  different  systems  (Head  and  Sherren). 

(a)  Epicritic  sensation,  or  appreciation  of  light  touch,  and  finer  sensa- 
tions, as  the  discrimination  of  compass-points,  minor  degrees  of  temperature, 
the  distribution  of  which  agrees  with  that  of  sensory  nerves  as  found  by 
anatomical  investigation. 

(b)  Protopathic  or  sensation  of  a  primitive  type,  chiefly  of  an  unpleasant 
nature  as  regards  touch  and  major  degrees  of  heat  and  cold — the  sensation  not 
being  localized  but  radiating  widely  and  having  a  much  wider  distribution 
than  would  be  supposed  from  the  anatomical  distribution  of  the  nerves, 
and  widely  overlapping  the  protopathic  supply  of  adjoining  nerves. 

(c)  Deep  sensation  and  muscular  sense,  conveyed  along  the  nerves  to  the 
muscles,  and  thence  along  the  tendons  to  more  peripheral  parts,  and  hence 
not  affected  by  division  of  cutaneous  nerves. 

On  reaching  the  cord  these  sensory  impulses  are  altered  in  arrangement 
and  carried  on  upwards  as  touch,  pain,  heat,  cold,  muscular  sense. 

The  impulses  conveying  sensations  of  pain,  heat,  and  cold  cross  in  the 
cord  as  they  enter,  travelling  up  in  the  central  grey  matter,  and  hence 
these  sensations  are  lost  on  the  opposite  side  to  that  of  a  lesion  of  the  cord. 


LESIONS  OF  THE  SPINAL  CORD  641 

Impulses  conveying  tactile  and  muscular  sensation  travel  up  the  cord  on 
the  same  side  for  a  considerable  distance,  hence  are  lost  on  the  same  side 
as  the  lesion  of  the  cord.  This  alteration  of  the  course  of  impulses  enables 
us  to  distinguish  lesions  of  the  spinal  cord  from  those  of  peripheral  nerves. 
Thus  in  a  lesion  of  the  cord,  pain  may  be  abolished  alone,  while  in  lesions 
of  nerves,  unless  tactile  sensation  be  abolished,  pain  will  still  be  appreciated. 
Again,  all  forms  of  tactile  sensation  are  equally  abolished  in  lesions  of  the 
cord,  whereas  sensation  of  deep  touch  (pressure  and  muscular  sense)  is 
often  retained  after  loss  of  appreciation  of  light  touch  from  division  of  a 
peripheral  nerve.  If  sensation  of  heat  and  cold  be  lost  from  a  cord  lesion 
there  will  be  no  sensation  whatever  of  this  sort,  whereas  in  lesions  of  nerves 
discrimination  of  minor  degrees  of  heat  and  cold  may  be  lost  (epicritic), 
while  distinction  of  greater  degrees  of  heat  and  cold  will  still  be 
appreciated  (protopathic).  And  if  minor  degrees  of  heat  and  cold  can 
no  longer  be  distinguished,  light  touch  will  be  unnoticed  and  the  dis- 
tinction of  points  of  a  pair  of  compasses  lost  in  case  of  nerve  lesions, 
whereas  in  affections  of  the  cord  the  finer  sensations  of  touch  may  be 
quite  intact  while  sensations  of  pain,  heat,  and  cold  are  entirely  lost. 
Sensation  of  passive  movement  is  lost  by  itself  in  lesions  of  the  cord,  but 
where  this  occurs  in  nerve  lesions  it  is  always  combined  with  loss  of 
sensation  of  deep  pressure. 

If  a  hemisection  of  the  cord  be  made  there  will  result  : 

( 1 )  On  the  same  side  belowthe  lesion, paralysis  of  muscles,  loss  of  muscular 
sense,  and  some  loss  of  tactile  sense. 

(2)  On  the  opposite  side,  part  of  tactile  sensation  and  all  sensation  of 
heat  and  cold  will  be  lost. 

(  omplete  Section  of  the  Coed  ;  Paeaplegia.  Paraplegia  is  the 
clinical  expression  for  the  result  of  a  division  of  the  spinal  cord,  complete 
or  incomplete,  and  caused  by  injury,  pressure  of  products  of  disease  outside, 
or  destruction  by  disease  inside  the  cord.  In  complete  paraplegia  there  is 
paralysis  of  sensation  and  motion  below  the  site  of  lesion,  voluntary  motion 
being  entirely  lost,  reflex  actions  being  preserved  to  a  varying  degree.  If 
a  complete  segment  of  cord  is  destroyed  both  the  conducting  paths  from 
1lif  higher  centres  and  the  reflex  lower  centres  at  the  site  of  lesion  are 
ihstroyed.     The  results  may  be  summed  up  as  follows  : 

(1)  There  is  motor  paralysis  of  the  lowrer-segment  type  of  the  muscles 
supplied  by  the  segment  destroyed,  i.e.  flaccid  paralysis,  wasting  of  muscles 
with  a  reaction  of  degeneration,  and  loss  of  tendon  reflex. 

(2)  Motor  paralysis  of  the  upper-segment  type  below  the  destroyed 
segment  of  cord,  the  muscles  being  spastic  with  increased  tendon  reflexes 
and  without  a  reaction  of  degeneration  (where  the  cord  is  completely  divided 
this  paralysis  is  flaccid). 

(3)  Complete  loss  of  all  forms  of  sensation  below  the  lesion  (tactile, 
thermal,  painful)  and  a  narrow  zone  of  hyperesthesia  at  the  junction  of  the 
skin  supplied  by  the  damaged  and  intact  portions  of  the  cord. 

(4)  Vasomotor  and  trophic  changes  below  the  site  of  cord  lesion  (the 
i  4r 


A  TEXTBOOK  OF  SURGERY 

lattei  are  to  some  extent  due  to  loss  of  sensation).     Bedsores  are  an  example 
of  these  chang 

(5)  Loss  of  sphincter  control  below  the  lesion.  The  bladder  and  rectal 
ceiities  may  aci  reflexly  (of  course  unconsciously)  if  the  lesion  is  well  above 
these  centres,  but  if  the  lesion  passes  through  the  bladder  and  rectal  centre 
in  the  cord  their  action  will  be  completely  destroyed  (resulting  in  overflow 
and  dribbling  incontinence).  Where  paraplegia  is  incomplete  the  sphincters 
may  not  be  affected  ;  thus  in  early  paraplegia  from  pressure  on  the  cord, 
in  tuberculosis  of  the  spine,  the  legs  may  be  weak  and  the  knee-jerks  in- 
<  I  before  the  sphincters  are  affected. 

Exploration  of  the  Cord  ;  Laminectomy.  The  importance  of  lumbar 
puncture  in  affections  of  the  brain  has  already  been  mentioned  ;  it  is  also 
useful  for  investigating  lesions  of  the  spinal  cord.  Laminectomy,  or  removal 
of  several  laminae  to  explore  the  cord,  is  employed  in  dealing  with  cases  of 
injury  (including  bullet- wounds),  of  the  spine  where  the  cord  is  affected,  as 
well  as  in  new  growths  or  inflammations  involving  the  spinal  cord.  The 
patient  lies  on  the  face  and  the  spine  is  approached  by  a  longitudinal  median 
incision  over  the  spines  of  several  vertebrae,  with  a  short  transverse  cut  at 
either  end  if  necessary.  The  muscles  and  tendinous  attachments  are  cleared 
off  the  spines  and  laminae  with  chisel  or  rugine  till  several  are  thoroughly 
exposed,  bleeding  is  checked  with  pressure-forceps  and  packing,  and  the 
laminae  are  divided  close  to  the  articular  processes  with  saw  or  forceps, 
removing  enough  to  obtain  a  good  view  of  the  cord.  Care  is  needed  in 
removing  the  laminae  not  to  injure  the  cord,  especially  if  adhesions  be 
present.  The  dura  is  examined  and  the  cord  palpated  through  the  latter, 
which  may  be  opened  under  conditions  described  later.  Owing  to  the 
shortness  of  the  cord  compared  with  the  spinal  canal  the  lower  nerves  come 
off  the  cord  at  a  higher  level  than  the  intervertebral  foramina  through 
which  they  emerge.     The  following  landmarks  will  be  useful  : 

The  cervical  nerve-roots  come  off  the  cord  each  opposite  the  cervical 
spine  one  above  their  number  (e.g.  the  third  nerve  opposite  the  second  spine). 
The  fourth  dorsal  spine  corresponds  to  the  sixth  dorsal  nerve-root,  the  sixth 
spine  to  the  ninth  root,  the  ninth  spine  to  the  twelfth  root,  and  the  eleventh 
dorsal  spine  to  the  third  lumbar  root. 

Congenital  Affections  of  the  Spine  and  Cord.  The  conditions 
described  are  spina  bifida  and  sacrococcygeal  tumour. 

Spina  Bifida.  This  congenital  defect  consists  in  failure  of  the  laminae 
to  join  together  at  some  point  in  the  length  of  the  spine,  leaving  a  gap  in 
the  posterior  surface  of  the  spinal  canal,  through  which  there  is  usually  a 
protrusion  of  the  spinal  cord  or  its  meninges. 

Occasionally  there  is  no  protrusion  but  the  gap  in  the  spinal  canal  is 
covered  with  skin  of  a  cicatricial  nature,  and  often  a  tuft  of  hair  will  be 
noted  in  this  situation  ;  this  condition  is  known  as  spina  bifida  occulta, 
and  is  as  a  rule  of  no  consequence,  though  congenital  tumours  may  grow  in 
the  defect  and,  pressing  on  the  cord,  require  operation.  The  cord  is  developed 
as  a  dorsal  epidermic  gutter  which  becomes  separated  from  the  skin  by  its 


SPINA  BIFIDA 


643 


Pr<..  246.    Spina  bifida  (meningoccele),  show- 
ing the  meninges  bulging  the  skin  and  sur- 
rounding a  norma]  spinal  cord  '/. 


inclusion  in  the  mesoblastic  somites  (myotomes),  which  form  vertebrae  and 
muscles.  The  former  ossify  from  three  centres,  one  of  the  body  and  one 
for  each  lamina.  In  cases  of  spina  bifida  the  centres  for  the  laminae  fail 
to  unite  behind,  allowing  the  contents  to  bulge  ;  there  must  be  some  defect 
in  the  cord  or  its  membranes  as  well  to  cause  the  bulging.  The  usual  position 
for  spina  bifida  is  the  lumbo-sacral 
region,  but  cases  occur  in  other  parts 
of  the  spine.  The  cord  is  often  de- 
formed and  paralyses  of  the  lower 
limbs  sometimes  are  found,  while 
Hub-foot  is  often  associated  with 
t  his  deformity.  There  are  two  main 
varieties  of  spina  bifida,  the  menin- 
gocoele  and  the  myelocoele,  of  which 
the  latter  is  by  far  the  more  com- 
mon. 

(1)  In  the  meningoccele  there  is 
a  bulging  of  the  dura  and  arachnoid 
filled  with  fluid,  the  cord  and  nerves 
occupying  a  normal  position  inside. 

(2)  In  the  myaloccele  the  central 
canal  of  the  cord  has  never  properly 
closed  and  the  flattened  cord  is 
adherent  to  the  cicatricial-like  skin 
over  the  sac;  from  the  atrophic. 
deformed  cord  nerves  pass  across 
the  sac  to  their  distribution  :  the 
central  canal  may  not  be  obviously 
open,  though  sometimes  cerebro- 
spinal fluid  leaks  out. 

This  is  by  far  the  most  common 
type  of  spina  bifida  and  is  some- 
times described  as  meningo-mye- 
loccele,  which  is  reasonable,  since 
both  cord  and  meninges  take  part 
in  the  formation  of  the  sac. 

(.".)  A  very  rare  condition  is  syringo-myeloccele,  in  which  the  cord,  in 
addition  to  being  contained  in  the  sac  of  meninges,  is  distended  from  a 
collection  of  fluid  in  the  central  canal,  which  is  much  enlarged. 

Signs.  A  mid-line  swelling  found  in  the  lower  part  of  the  back,  covered 
in  part  with  normal  skin  but  over  the  larger,  more  central  area  by  bluish 
or  purple  thin  translucent  membrane,  partly  reducible  and  having  an 
impulse  when  the  infant  cries,  are  the  Bigns  of  this  condition.  The  swelling 
is  partly  reducible  on  pressure,  causing  the  anterior  fontanelle  to  bulge; 
the  detect  in  the  vertebrae  can  be  detected  on  deep  palpation.  The  sac  is 
translucent  to  a  varying  degree,  being  more  so  in  pure  meningoceles  than 


Fig.  247.  Myelocoele  (diagrammatic  section). 

a.  Integuments,  b,  Meninges,  c.  Nerve  cords. 

'/.  Spinal  cord,  of  which  the  central  canal  is 

not  closed. 


GU  A  TEXTBOOK  OF  SURGERY 

in  myelocoeles,  in  which  the  nerves  may  Bometimes  be  seen  running  a< 
the  sac,  though  it  must  be  confessed  that  very  often  no  trace  of  them  can 
be  soon  by  transmitted  light.     If  left  alone  most  of  these  protrusions  burst 
and  death  from  meningitis  will  soon  follow,  but  some  remain  of  constant 
size,  especially  pure  meningoooeles  with  a  good  covering  of  skin. 

Diagnosis.  This  deformity  can  hardly  be  mistaken  for  anything  else. 
We  have  known  an  enthusiastic  dresser  open  one  in  mistake  for  an  abscess, 
hut  the  position,  congenital  nature,  translucency,  and  impulse  on  crying 
should  prevent  this  mistake. 

Treatment.  Operative  treatment  is  needed  in  myelocoeles  as  soon  as 
possible  after  birth  before  the  sac  bursts  and  infection  takes  place,  though 
we  have  known  a  case  with  the  sac  burst  and  plastic  lymph  amongst  the 
meninges  recover.  In  the  case  of  pure  meningocceles  with  a  good  covering 
of  normal  skin  the  swelling  may  be  left  for  a  few  months  till  the  tissues  are 
stronger.  The  presence  of  hydrocephalus  is  generally  considered  a  contra- 
indication to  operation,  but  there  seems  no  reason  why  an  attempt  should 
not  be  made  to  cure  both  conditions. 

In  the  case  of  pure  meningocceles  the  skin  is  dissected  off  the  sac  and  the 
latter  opened,  redundant  meninges  cut  away  and  the  thecal  sac  closed, 
flaps  of  fascia  or  muscles  cut  from  the  side  of  the  aperture  in  the  spinal 
canal  and  brought  over  the  gap.  The  operation  is  similar  in  myelocoeles, 
but  it  will  be  necessary  to  remove  most  of  the  thecal  sac  with  the  overlying 
membrane-like  skin  and  the  adherent  part  of  the  cord  underneath.  As 
little  as  possible  of  the  cord  is  removed  and  the  nerves  are  spared  as  far 
as  may  be  ;  bleeding-points  on  the  cord  are  tied,  the  sac  closed  over  it, 
and  flaps  of  muscle  or  fascia  made  to  cover  over  the  gap  as  before,  the  skin 
finally  closed  :  often  lateral-tension  incisions  will  be  made  in  the  loins  to 
allow  of  the  skin  meeting  in  the  mid-dorsal  line. 

A  certain  number  of  cases  recover,  though  the  mortality  is  heavy. 

Sacrococcygeal  Tumours.  Various  tumours  of  congenital  origin  are 
found  over  the  lower  posterior  part  of  the  spine,  some  of  which  are  con- 
sidered to  be  due  to  some  abnormal  development  of  the  neurenteric 
canal,  which  connects  the  central  canal  of  the  foetal  spinal  cord  with  the 
primitive  alimentary  canal.  A  common  relic  of  this  is  the  "  post-anal 
dimple,"  a  depression  over  the  tip  of  the  coccyx  from  which  sometimes  a 
tuft  of  hair  springs.  The  tumours  of  this  region  may  be  simple  dermoid 
or  complicated  tumours  containing  several  varieties  of  tissue,  and 
which  may  be  teratomas  allied  to  the  condition  of  "  conjoined  foetus," 
containing  glands,  muscles,  cartilages,  &c.  In  some  cases  malignant  changes 
develop,  so  in  most  instances  these  tumours  should  be  removed  by  dissection. 

Injuries  of  the  Spine.  The  following  affections  are  described : 
(1)  sprains  ;  (2)  punctured  wounds  ;  (3)  dislocations  and  fractures,  which 
last  are  often  combined. 

As  regards  the  skeletal  functions  of  the  spinal  column  these  injuries  are 
of  comparatively  minor  importance,  their  real  gravity  consisting  in  the 
liability  of  the  spinal  cord  to  be  injured  by  displaced  bones,  effused  blood, 


[NJURIES  OF  THE  SPIXE  645 

formation  of  pus,  fibrous  tissue,  or  callus  as  the  result  of  such  injury,  not 
to  mention  the  development  of  traumatic  neuroses. 

(1)  Sprains  and  Contusions.  These  arise  from  twists  and  blows,  as  in 
railway  or  riding  accidents,  with  the  result  that  blood  is  effused  into  the 
spinal  muscles  and  ligaments  and  more  rarely  into  the  spinal  canal,  with 
possible  affection  of  the  spinal  cord. 

Signs.  The  patient  complains  of  some  pain  but  much  more  of  tenderness 
on  moving,  twisting,  or  palpating  the  affected  region.  There  will  be, 
however,  no  paralysis  or  alteration  of  sensation  below  unless  the  cord  be 
injured,  and  no  displacement  of  the  spines  of  the  vertebra)  or  any  abnor- 
mality seen  in  a  radiograph. 

Treatment.  The  patient  is  kept  in  bed  for  three  days  and  watched  for 
the  advent  of  signs  of  compression  of  the  cord  due  to  intraspinal  bleeding, 
and  if  this  does  not  occur  he  can  soon  be  allowed  up  and  massage  and 
movements  practised. 

(2)  Pud  (in  nil  Wounds  <>f  ///<•  Spine.  These  are  the  result  of  stabs,  falls 
on  pointed  objects,  or  bullet-wounds.  The  important  effects  vary.  There 
may  be  fracture  of  the  vertebrae  with  compression  or  other  injury  of  the 
cord  by  the  penetrating  object  or  fragments  of  bone,  or  haemorrhage  causing 
compression  of  the  spinal  cord  or  severe  bleeding,  as  in  the  cervical  region, 
where  the  vertebral  artery  may  be  injured,  or  the  pleura  or  peritoneum 
may  be  opened.  The  meninges  may  be  opened,  affording  ingress  to 
infective  organisms  and  rapidly  spreading  meningitis,  or  the  cord  may  be 
divided  partially  or  completely.  The  results  of  injury  to  the  cord  are 
discussed  later. 

Treatment.  The  wound  should  be  explored  fully,  which  will  usually 
imply  laminectomy,  removing  clots,  fragments  of  bone  or  foreign  bodies, 
and  rendering  the  part  as  aseptic  as  possible. 

(3)  Fractures  and  Dislocations.  These  commonly  occur  together,  the 
articular  processes  being  broken  off  and  the  bodies  dislocated  at  the  inter- 
vertebral disc  or  fractured  through  their  substance.  Pure  dislocations  can 
ha  idly  occur  except  in  the  cervical  region.  Pure  fractures  occur  in  the 
lamina'  and  spines,  less  often  in  the  transverse  processes,  from  direct  violence. 
From  a  practical  point  of  view  we  may  divide  these  injuries  into  :  complel  . 
\\  here  the  line  of  the  spine  as  a  whole  has  been  broken  across  and  the  cor  I 
is  almost  certainly  injured,  and  the  incomplete,  where  spines  or  laminae  aTe 
broken  ami  there  is  a  good  prospect  of  the  cord  escaping  injury. 

Causes.     Fracture-dislocations  may  be  due  to  direct  or  indirect  violence 

(a)  Direct  violence,  as  falls  on  the  back  across  a  narrow  object  such 
as  the  top  of  a  gate,  or  heavy  blows  with  similar  objects,  fust  crush  the 
spines,  then  the  lamina',  and  if  the  violence  is  very  great  the  spine  may  be 
hyperextended  and  the  bodies  of  the  vertebrae  torn  asunder. 

(b)  Indirect  violence,  from  forcible  hyperflexion.  as  when  a  heavy 
body  falls  on  the  upper  part  of  the  back  in  the  stooping  position  or  falling 
from  a  height  with  the  spine  hyperextended,  as  in  diving.  The  result  of 
hyperliexion  is  to  crush  the  bodies  together,  fracture  the  articular  processes, 


646  \  TEXTBOOK  OF  SURGERY 

and  separate  the  laminae,  while  in  hyperextensioo  the  Bpines  and  lamina 
are  crashed  together  and  the  bodies  torn  apart.  In  practically  all  cases 
the  upper  part  of  the  column  is  dislocated  forward  on  the  lower ;  the  dislo- 
I  parts  may  fall  hack"  again  into  normal  position  immediately,  but  in 
the  act  of  dislocation  the  cord  is  usually  crushed. 

Pure  fractures,  or,  as  they  may  be  called,  incomplete  fractures  (because 
the  alignment  of  the  spinal  column  is  not  broken),  occur  mostly  in  the 
dorsal  region,  because  in  the  cervical  portion  the  spines  are  shorter,  the 
parts  more  mobile  and  covered  with  muscles — hence  if  deformity  takes  place 
Mom  excessive  violence  it  will  be  more  often  dislocation  or  fracture-dislo- 
cation :  while  in  the  lumbar  region  the  spines  are  short  and  strong,  not 
easily  broken  by  themselves,  and  well  covered  with  muscles.  If  the  spines 
only  are  fractured  no  injury  will  result  to  the  cord  unless  from  concussion 
or  bleeding  inside  the  spinal  canal  from  laceration  of  ligaments.  If  both 
the  lamina?  are  broken  the  cord  is  likely  to  be  compressed  or  pulped,  but  if 
one  only  is  affected  the  cord  may  escape. 

Pure  dislocations  can  only  happen  in  the  cervical  region  on  account  of 
the  articular  facets,  which  are  inclined  at  only  a  small  angle  with  the  hori- 
zontal and  readily  allow  of  slipping  and  dislocation,  whereas  in  the  dorsal 
and  lumbar  regions  they  are  vertical  and  in  the  latter  place  much  larger,  so 
that  separation  without  fracture  cannot  occur.  Even  in  the  cervical  region 
fracture  often  complicates  dislocation. 

Dislocation  between  any  two  of  the  lower  cervical  vertebrae  may  be  of 
one  or  both  articulations  and  may  be  partial  or  complete  ;  in  addition  there 
will  be  some  tearing  of  the  vertebral  disc  and  ligaments.  Where  the  dislo- 
cation is  unilateral  there  is  usually  no  pressure  on  the  cord,  though  the 
nerves  may  be  stretched  or  compressed  as  they  pass  the  intervertebral  notch. 
When  the  dislocation  is  bilateral  and  complete  there  is  apt  to  be  severe 
pressure  on  the  cord,  often  fatal ;  still,  in  a  fair  number  of  cases  even  with 
this  severe  deformity  there  is  no  pressure  on  the  cord. 

Injuries  to  the  atlas  and  axis  assume  a  special  form  owing  to  the  different 
shapes  and  methods  of  articulation  of  these  bones.  Rarely  the  atlas  has 
been  torn  from  the  occiput,  causing  sudden  death  if  complete. 

Separation  of  the  atlas  and  axis  is  one  of  the  results  of  hanging,  and  in 
this  case  the  odontoid  process  is  often  fractured  through  its  base.  The 
art  of  lifting  a  child  by  its  head  has  caused  this  accident,  and  in  one  instance 
at  least  the  accident  was  repeated,  in  showing  how  it  occurred,  on  another 
child. 

In  a  good  many  cases,  however,  the  dislocation  is  unilateral  and  rotary, 
and  if  the  odontoid  process  is  intact  is  seldom  fatal,  though  myelitis  may 
come  on  considerably  later  with  fatal  result  :  this  may  result  from  slight 
injuries. 

Signs  of  Fracture  of  the  Spine.  These  depend  :  (a)  on  the  dis- 
placement of  bones  ;   (b)  on  the  injury  of  the  cord. 

(a)  In  examining  for  displacement  of  the  vertebrae  the  greatest  care 
must  be  taken  not  to  make  matters  worse  by  causing  further  displacement. 


SIGNS  OF  FRACTURED  SPINE 


647 


In  many  instances  the  deformity  is  not  easy  to  detect :  the  spines  should 
be  palpated  all  the  way  along  the  column,  any  deformity  forward,  backward, 
or  laterally  noted.  The  bodies  can  only  be  palpated  in  the  case  of  the 
cervical  vertebra)  1  to  6,  and  these  from  the  pharynx.  Crepitus  may 
be  noted  incidentally,  but  no  attempts  should  be  made  to  obtain  this  sign 
lest  the  cord  be  further  injured.  Deformity  is  often  well  marked  in  cervical 
dislocations  :  if  bilateral,  the  head  is  thrust  forward  in  the  "  poked  head  " 
position  ;  if  unilateral,  the  head  is  rotated,  the  chin 
facing  away  from  the  side  of  dislocation  (which  is 
forward). 

In  all  doubtful  cases  of  spinal  injury  radiographs 
should  be  taken  in  two  planes,  as  diagnosis  of  osseous 
lesions  is  often  very  difficult. 

(b)  Cord  and  Nerve  Lesions.  It  is  from  these  that 
fracture  of  the  spine  is  usually  diagnosed,  and  its 
position  located  by  the  amount  of  paralysis  and 
anaesthesia.  Shock  is  a  marked  feature.  In  minor 
degrees  of  displacement  there  will  be  numbness, 
tingling,  and  pain  along  the  course  of  the  nerves 
at  the  site  of  injury ;  this  is  particularly  noted  in 
partial  or  unilateral  dislocations  of  the  cervical  spine 
(e.g.  occipital  neuralgia  in  atlanto-axial  dislocation). 
If  the  cord  is  severely  injured  the  following  results 
will  be  found  according  to  the  level  of  the  lesion  : 

(1)  Above  the  fourth  cervical  vertebra,  owing  to 
injury  of  the  motor  cells  of  the  phrenic  nerve,  cessa- 
tion of  respiration  and  death  occur  in  a  few  minutes. 

(2)  In  the  lower  cervical  region  there  will  be 
paralysis  of  all  the  limb  and  trunk  muscles,  respira- 
tion being  carried  on  by  the  diaphragm  ;  as  coughing 
is  impossible  the  patient  is  liable  to  congestion  of 
the  lungs,  and  generally  dies  in  a  few  days  of  pul- 
monary oedema  or  hypostatic  pneumonia.  Where  the  lesion  is  in  the 
cervical  region  just  below  the  fifth,  cervical  root  the  arms  are  held  above 
the  head  with  the  forearms  semiflexed,  owing  to  the  unopposed  action  of 
the  muscles  supplied  by  the  filth  cervical  nerve. 

(3)  In  the  upper  dorsal  region  the  arms  escape  paralysis  but  are  often 
hypersesthetic,  and,  as  in  the  former  condition,  pulmonary  cedema  closes 
the  scene  in  a  few  days.  Priapism,  meteorism  (which  may  embarrass 
respiration)  and  alteration  of  the  pupils  from  irritation  or  paralysis  of  the 
cilio-spinal  centre  in  the  upper  part  of  the  dorsal  cord  may  also  be  noted, 
with  lesions  at  this  level. 

(4)  If  the  lesion  is  in  the  dorsi-lumbar  region  the  abdominal  muscles 
escape,  so  that  coughing  is  possible  and  lung  affections  less  likely  to  occur. 
The  lower  limbs  are  paralysed  and  a  zone  of  hyperesthesia  is  found  around 
the  loins  above  the  anaesthesia,  causing  severe  girdle  pain  (as  if  the  body 


FlG.  248.      Fracture-dis- 
location of  the  vertebral 
column,  showing  how  the 
cord  is  compressed. 


A  TEXTBOOK  OF  SURGERY 

wore  held  in  a  vice).  If  the  lesion  be  above  the  vesical  centre  of  the  cord, 
after  a  period  of  retention  with  overflow,  reflex  micturition  will  take  place, 
but  if  the  lumbar  enlargement  be  crushed  there  will  be  persistent  retention 

with  overflow,  requiring  catheterization:  incontinence  of  faeces  is  the 
rule. 

The  main  danger  in  these  cases  lies  in  the  risk  of  infection  of  the  bladder 
from  the  necessary  catheterization,  leading  to  cystitis  and  renal  infection, 
usually  fatal  in  a  few  months— for  which  reason  the  most  scrupulous  care 
is  needed  in  passing  catheters  on  these  patients. 

(5)  "Where  the  fracture  is  in  the  lower  lumbar  or  sacral  regions  the  cord 
will  escape  but  the  corda  equina  will  be  injured,  the  extent  depending  on 
the  level  of  fracture.  Thus  the  lumbar  region  may  escape  entirely,  so 
that  paralysis  is  confined  to  the  hamstrings,  legs,  and  sphincters,  with 
anaesthesia  of  the  penis,  scrotum,  gluteal  region,  and  the  lower  limbs  except 
the  front  and  inner  side  of  the  thigh  and  the  inner  side  of  the  leg  and  toot 
(supplied  by  the  anterior  crural  nerve). 

Varieties  of  Lesions  of  the  Cord.  These  paraplegic  effects  are 
produced  by  various  lesions  of  different  degrees  of  severity,  viz.  :  (1)  con- 
cussion,  (2)  haemorrhage,   (3)  crushing,   (4)  myelitis,  (5)  meningitis. 

(1)  Spinal  Concussion.  The  functions  of  the  cord  may  be  thrown  out 
of  gear  by  a  severe  blow  without  fracture  of  the  bones  or  any  known  ana- 
tomical lesion.  The  condition  clinically  resembles  a  paraplegia  from  crushing 
of  the  cord  or  pressure  by  haemorrhage,  except  that  recovery,  which  may  be 
perfect,  will  take  place,  and  also  in  the  cervical  region  the  paralysis  affects 
the  arms  more  than  the  legs,  presumably  because  the  grey  matter  containing 
the  motor-cells  is  more  affected  by  concussion  than  the  white  conducting 
tracts  leading  to  the  motor-cells  of  the  lower  limb  ;  moreover,  priapism,  so 
common  in  injuries  of  the  cervical  region,  is  said  not  to  be  found  in  cases 
of  spinal  concussion. 

The  diagnosis  is  often  impossible,  but  recovery  after  paraplegia  due  to 
spinal  injuries  is  generally  regarded  as  of  this  nature. 

(2)  Hemorrhage  info  the  Spinal  Canal  from  Injury.  This  may  be  extra- 
or  intramedullary,  according  as  it  is  outside  or  inside  the  cord. 

(a)  Extramedullar)/  Hemorrhage  (haemato-rhachis).  This  results  from 
fractures  or  other  injuries  of  the  spinal  column,  and  is  usually  outside  the 
dura  mater,  producing  symptoms  of  pressure  on  the  cord.  The  signs  are 
those  of  spinal  irritation,  pains,  rigidity,  spasms  and  cramps,  arising  a  few 
hours  after  injury,  without  fever,  and  passing  into  paraplegia,  which  gradually 
spreads  upwards. 

(b)  Intramedullary  Hemorrhage  (haematomyeha).  Where  the  bleeding 
is  gross  the  signs  will  resemble  those  of  crushing  or  myelitis ;  when  of 
more  limited  extent  the  signs  may  be  localized  and  give  some  chance  of 
diagnosis.  Thus  the  haemorrhage  may  affect  half  the  cord,  causing  paralysis 
on  the  same  side  below  and  loss  of  sensations  of  heat,  cold,  and  pain  on 
the  opposite  side.  The  paralysis,  if  the  bleeding  be  in  the  cervical  region, 
will  be  flaccid  in  the  arm,  spastic  in  the  leg ;    if  the  bleeding  be  central, 


LESIONS  OF  THE  SPINAL  CORD  649 

sensation  of  heat  and  cold  may  be  lost  on  both  sides  while  tactile  sense 
may  be  left  unaffected.  The  absence  of  spinal  irritation  distinguishes  the 
condition  from  extramedullary  haemorrhage.  There  is  considerable  prospect 
of  the  haemorrhage  spreading  and  the  paralysis  becoming  of  wider  distribu- 
tion and  ultimately  fatal,  but  it  may  remain  localized,  and  after  the  blood 
is  absorbed  there  will  be  left  some  paresis  of  the  upper  limb  and  spasticity 
of  the  leg  if,  as  is  usually  the  case,  the  bleeding  is  in  the  cervical  cord. 
Smaller  haemorrhages  may  pick  out  single  groups  of  muscles. 

(c)  Crushing  and  Myelitis.  When  the  cord  is  severely  lacerated  or 
crushed  by  injury  the  signs  are  those  of  complete  division,  as  previously 
described.  In  addition  to  this,  however,  and  commencing  at  the  place 
where  the  cord  was  crushed,  or  sometimes  after  injuries  where  there  has 
been  at  the  outset  no  discoverable  lesion,  the  cord  may  undergo  a  spreading 
inflammation  or  degeneration,  becoming  congested  and  softened,  the  nerve- 
fibres  swelling  up  and  degenerating,  the  motor-cells  degenerating  and  losing 
their  staining  reactions,  and  finally  in  severe  instances  the  whole  becoming 
converted  into  a  spongy,  pulpy,  shapeless  mass. 

This  procebS  of  degeneration  is  known  as  myelitis,  and  the  signs  are 
primary  paraplegia  at  the  level  of  injury  ;  but  the  level,  instead  of  remaining 
constant,  travels  upwards,  as  shown  by  the  spread  of  anaesthesia  and  paralysis. 
The  process  may  also  spread  downwards,  as  shown  by  the  loss  of  reflexes 
which  have  been  present  and  by  the  paralysis  altering  from  spastic  to  flaccid 
owing  to  destruction  of  the  motor-cells  of  the  anterior  horn.  At  the  onset 
of  paraplegia  there  may  be  pains  and  cramps,  but  this  is  a  much  less  marked 
feature  than  in  extramedullary  haemorrhage  or  meningitis.  Loss  of  sphincter 
control  and  bed-sores  are  present  in  these  cases. 

(d)  Acute  Spinal  Meningitis.  This  usually  follows  infected,  punctured 
wounds  of  the  meninges,  but  rarely  following  simple  injuries,  and  also 
spreads  from  the  cerebral  meninges  as  pyogenic  or  cerebro-spinal  meningitis. 

Anatomy.  This  concerns  chiefly  the  pia-arachnoid,  which  are  congested 
and  filled  with  purulent  exudate. 

Signs.  The  onset  is  sudden  with  high  fever,  frequently  an  initial  rigor, 
great  pain  in  the  back  radiating  to  the  limbs,  rigidity  and  spasms  of  the 
muscles,  rapid  emaciation,  and  other  signs  of  fever.  Usually  the  cord  is 
soon  affected — myelitis  and  paraplegia,  with  loss  of  sphincter-control  and 
bed-sores  rapidly  resulting  :  in  some  instances  the  inflammation  will  spread 
to  the  cerebral  meninges,  causing  death  from  coma.  Very  uncommonly  the 
condition  passes  into  a  more  chronic  stage,  and  recovery  is  not  unknown. 

Prognosis  of  Spinal  Injuries.  Where  there  is  no  injury  to  the  cord  the 
outlook  is  good,  though  unreduced  dislocations  of  the  cervical  vertebrae 
may  cause  much  stiffness,  pain  and  incapacity,  and  sometimes  lead  to 
myelitis  later. 

When  the  lesion  involves  the  cord  the  prospect  is  bad,  if  in  the  upper 
part  as  regards  life,  if  in  the  lower  part  as  regards  locomotion.  If  the 
lesion  is  in  the  cervical  region  and  is  not  immediately  fatal,  i.e.  below  the 
origin  of  the  phrenics,  the  patient  usually  dies  in  two  or  three  days,  either 


A  TEXTBOOK  OK  Sl'HCiKRY 

from  myelitis  spreading  up  to  the  phrenic  motor-cells  or  from  failure  fco 
cough  causing  hypostatic  pneumonia.  In  the  upper  dorsal  region  also  death 
is  usual  after  a  few  weeks  from  hypostatic  pneumonia,  though  a  few  patients 

survive  some  time.  If  the  lesion  is  in  the  lower  dorsal  region  the  patient 
may  drag  on  for  months  with  increasing  urinary  infection,  gradually  suc- 
cumbing to  renal  infection,  but  exceptional  instances,  carefully  treated, 
live  for  years,  the  bladder  and  rectum  acting  reflexly  and  infection  not 
occurring  or  being  cured.  These  patients  simply  have  paralysed  and 
insensitive  legs  and  bladder,  and  with  attention  live  fairly  comfortably. 
In  the  lower  lumbar  or  sacral  regions  where  the  cauda  equina  is  injured 
the  patient  may  make  a  good  recovery,  or  with  some  paralysis  of  legs  or 
sphincters.  Traumatic  neurosis  is  common  after  spinal  injuries,  often 
of  the  minor  varieties. 

Treatment  of  Spinal  Injuries.  The  aim  of  the  surgeon  in  dealing 
with  the  patients  is  to  prevent  the  cord  from  being  injured  by  displaced  bone, 
or,  if  injured,  to  prevent  this  becoming  worse,  occasionally  to  relieve  pressure 
on  the  cord,  and  to  prevent  the  effects  of  paralysis  in  the  shape  of  pneu- 
monia, urinary  sepsis,  and  bed-sores.  To  prevent  further  injury  the  greatest 
care  must  be  taken  in  moving  the  patient,  and  later,  when  washing  him  or 
attending  in  other  ways,  taking  care  that  the  parts  above  and  below  the 
fracture  are  moved  together  and  equally.  The  patient  should  be  placed 
on  his  back  on  a  firm  mattress  stuffed  with  horsehair. 

Spring-mattresses  are   to    be    avoided    in    these  cases    and    fracture- 
boards  substituted  ;   water-pillows  under  the  sacrum  will  help  to  avoid  the 
formation  of  bed-sores.     In  most  instances  reduction  of  the  fracture  will 
take  place  when  the  patient  is  placed  supine.     Should  this  not  take  place, 
and  if  the  paraplegia  is  incomplete,  careful  attempts  should  be  made  to 
reduce  the  deformity  by  traction  under  anaesthesia,  and  in  selected  cases 
by  operative  measures  (see  below,  Operative  Measures).     Such  cases  are 
usually  those  of  cervical  dislocations,  and  reduction  is  done  by  traction  of 
the  head  combined  with  flexing  the  neck  to  the  sound  side  (to  disentangle 
the  articular  process),   followed   by  rotating  the  head  back  towards  the 
dislocated  side.     Where  dislocation  is  reduced  by  such  measures  it  will  be 
sound  practice  to  steady  the  head  and  neck  in  a  plaster-case,  but  in  most 
cases  the  application  of  a  plaster- jacket  will  be  likely  to  cause  more  damage 
to  the  cord  during  the  necessary  manipulations.     When  the  patient  is  safely 
on  his  back  the  matter  becomes  one  of  nursing.     The  diet  should  be  light, 
the  lower  bowel  emptied  with  an  enema  daily,  and  the  bladder  emptied 
by  catheter  as  necessary,  with  all  aseptic  technique.     To  prevent  bedsores, 
the  back,  and  especially  the  sacrum  and  heels,  need  constant  attention. 
Regular  washing  twice  daily  with  non-irritating  soap  and  water,  gentle 
drying  and  light  friction  with  spirit,  followed  by  a  dusting-powder  of  starch 
and  boric  powder  and  frequent  slight  rearrangements  of  the  water-pillows, 
&c.,  to  alter  the  points  of  pressure,  will  keep  the  skin  in  good  order.     (  ii- 
cular  pads  to  take  pressure  off  the  heels  and  a  cradle  to  prevent  the  feet 
from  becoming  "  dropped  "  are  essential. 


TREATMENT  OF  FRACTURED  SPINE  651 

(  a  re  is  needed  in  the  earlier  stages  not  to  injure  the  patient  by  the  use 
of  over-hot  bottles  when  relieving  shock,  as  the  insensitive  skin  is  readily 
burnt  and  may  lead  to  intractable  ulcers.  The  treatment  of  bedsores 
is  discussed  under  the  surgery  of  Ulcers.  The  bladder  at  first  will  require 
regular  emptying  with  a  catheter,  though  later  reflex  micturition  may  be 
established.  The  catheter  should  be  of  soft  rubber,  boiled  before  use,  and 
the  anterior  urethra  should  be  cleaned  by  washing  out  with  oxycyanide  of 
mercury  1  in  200  after  swabbling  the  penis  with  biniodide  of  mercury 
1  in  4000  ;  care  in  this  respect  can  hardly  be  overdone,  as  failure  in  urinary 
asepsis  is  the  most  usual  cause  of  death.  When  cystitis  is  present  the 
bladder  should  be  washed  out  with  oxycyanide  of  mercury,  and  if  severe, 
instillation  of  silver  nitrate  practised.  Urotropin  and  acid  phosphate  of 
sodium  are  given  internally  (see  Cystitis  under  Surgery  of  the  Bladder). 
Where  there  is  likelihood  of  oedema  of  the  lungs,  atropin  should  be  adminis- 
tered, but  these  cases  seldom  recover. 

Operative  Treatment.  This  is  indicated  in  some  cases,  but  usually 
the  cord  is  too  much  injured  to  recover  even  after  pressure  has  been  removed. 

Indications  from  laminectomy  in  cases  of  spinal  injury  : 

(1)  Penetrating  Wounds.  In  these  cases  the  wound  should  be  thoroughly 
explored,  fragments  of  bone  or  foreign  bodies  removed,  and  the  wound 
thoroughly  cleaned,  not  merely  with  a  view  of  relieving  pressure  on  the 
cord  but  to  anticipate  and  prevent  the  even  more  imminent  danger  of 
infection  and  meningitis.  It  will  be  reasonable  to  operate  with  a  view  of 
preventing  infection  even  in  cases  where  it  is  certain  that  the  cord  has  been 
completely  divided. 

(2)  In  dislocations  of  the  cervical  region  with  signs  of  pressure  on  the 
cord,  since  there  is  considerable  prospect  that  the  cord  in  these  cases  may 
not  be  completely  crushed.  In  these  cases  it  is  not  sufficient  to  remove 
laminae  but,  in  addition,  to  explore  the  articular  processes  and  reduce  the 
dislocation  by  traction  levering,  or  removal  of  part  of  the  articular  facet 
of  the  lower  (posterior)  process.  Having  reduced  the  deformity,  the  interior 
of  the  canal  should  be  explored  and  clots,  &c,  removed. 

('■))  In  cases  of  fracture  of  the  laminae  with  signs  of  lesion  of  the  cord, 
especially  if  incomplete  division  is  diagnosed,  operation  and  removal  <>| 
depressed  parts  <>l  lamina1  are  worth  undertaking. 

(4)  Where  the  pressure  on  the  cord  is  due  to  extramedullar)-  haemor- 
rhage, as  shown  by  its  onset  with  pain,  cramps,  &c.,  a  few  bonis  alter  the 
injury. 

(5)  In  some  instances  where  the  lesion  of  the  cord  is  incomplete,  as 
shown  by  recovery  of  the  deep  reflexes  some  time  after  injury. 

(<i)  Where  the  cud  symptoms  develop  later  owing  to  inflammatory 
exudation,  or  still  later  owing  to  cicatrization,  operation  should  always  he 
performed. 

(7)  In  lesions  of  the  lower  lumbar  and  sacral  regions,  since  the  cauda 
equina  is  really  a  bunch  of  peripheral  nerve?,  and  if  divided  nerves  are 
sutured  there  is  some  prospect  of  regeneration  taking  place  (though  in  the 


\    rEXTBOOK  OF  SUKGEItt 

cord  such  regeneration  of  conducting  tracts  appears  never  to  take  place), 
divided  branches  of  the  cauda  being  sutured.  Tin'  commencement  of  this 
operation  has  already  been  described  :  the  technique  after  opening  the 
laminae  is  exploratory,  removing  clots,  fragments  of  bone,  pus,  cicatrices,  &c. 
Inflammations  and  Degenerations  or  THE  Cord.  Tlie.se  belong  for 
the  most  part  to  physicians  and  neurologists,  seldom  coming  into  surgical 
cognizance  with  the  exception  of  anterior  poliomyelitis,  which,  from  its 
surgical  aspects,  is  described  in  the  section  on  Surgery  of  the  Locomotor 
S  stem  (pp.  552-554),  and  compression  myelitis,  which  demands  a  brief 
notice,  since  surgical  measures  are  often  suitable  in  these  cases. 

( '(impression  Myelitis.  This  term  is  applied  to  degeneration  of  the  cord 
caused  by  prolonged  pressure.  The  common  cause  is  caries  of  the  spine, 
less  often  new  growth  of  the  spinal  column  ;  aneurysms  and  hydatids  also 
produce  pressure  in  some  instances.  Caries  is  usually  tuberculous,  less 
often  syphilitic,  and  new  growths  are  usually  secondary,  not  infrequently 
to  cancer  of  the  breast,  but  primary  sarcoma  of  the  vertebrae  also  occurs. 
The  vertebrae,  cord,  and  nerves  are  affected. 

The  vertebrae  show  rigidity,  tenderness  and  deformity,  discussed  in 
detail  in  the  section  on  Diseases  of  the  Spine.  Pressure  on  nerves  and 
cord  is  seldom  due  to  the  acuteness  of  the  curve  but  to  growth  of  granulation- 
tissue  or  pressure  of  an  extradural  abscess  or  fibrous  scarring  around  the 
cord  and  nerves.  Pressure  on  the  nerves  causes  painful  areas  to  arise, 
referred  to  the  course  of  the  latter,  and  these  areas  may  be  anaesthetic  to 
touch  or  pressure  (anaesthesia  dolorosa)  ;  wasting  and  degeneration  of  the 
muscles  supplied  by  such  compressed  nerves  will  also  take  place. 

Pressure  on  the  cord  produces  weakness  of  the  legs  with  increased 
reflexes  and  an  uplifting  plantar  reflex  (Babinski),  which  passes  later  into 
a  paraplegia  of  the  upper-segment  (spastic)  type. 

Diagnosis.  From  tumours  inside  the  spinal  canal  this  is  made  by  the 
presence  of  deformity  of  the  spine  or  the  detection  of  a  focus  of  disease 
seen  in  a  radiograph,  or  the  presence  of  cancer  of  the  breast  or  elsewhere 
likely  to  give  rise  to  a  metastasis  in  the  spine,  and  by  the  paralysis  being 
more  often  bilateral  than  when  the  tumour  is  in  the  cord  or  meninges. 

Treatment  is  seldom  of  much  permanent  benefit  except  when  due  to 
caries,  when  complete  rest  in  the  recumbent  position  with  the  spine  fixed 
in  splint  or  plaster  may  cure.  If  this  fail  after  trial  for  two  to  three  months 
or  if  the  paraplegia  rapidly  becomes  worse,  as  shown  by  severe  cystitis  or 
bedsores,  laminectomy  and  removal  of  pus  and  granulation-tissue  should 
be  performed.  In  case  of  growth  benefit  from  operation  is  improbable, 
but  where  the  diagnosis  is  uncertain  and  there  is  a  possibility  that  there  is 
a  tumour  in  the  spinal  canal,  exploratory  laminectomy  should  be  done  if 
mercury  and  iodides  do  not  relieve  the  condition. 

New  Growths  and  other  Tumours  of  the  Spine  and  Cord. 
Tumours  of  the  cord  may  originate  in  the  nervous  tissue  proper  or  the 
meninges  or  spread  inwards  from  the  spinal  column.  The  latter  cases 
are  included  under  Compression  Myelitis. 


TUMOURS  OF  THE  SPINAL  CORD  653 

Tumours  are  more  common  in  the  meninges  than  the  cord  proper,  with 
the  exception  of  tuberculous  masses,  which  may  occur  in  the  nervous  matter. 
In  the  meninges  tumours  may  be  either  intra-  or  extradural,  including 
sarcomas  of  varying  rate  of  growth,  endotheliomas,  while  gliomas  are  found 
in  the  nervous  tissue.     Gummata  occur  in  both  cord  and  meninges. 

Signs,  (a)  Meningeal  Tumours.  There  will  be  pain  radiating  along 
the  course  of  the  nerves  at  the  site  of  the  lesion,  with  lower-segment  (flaccid) 
paralysis  of  the  muscles  supplied  by  these  nerves  and  upper-segment 
(spastic)  weakness  of  the  leg  on  the  side  of  the  lesion  due  to  pressure  on 
the  pyramidal  tract,  while  on  the  side  opposite  the  lesion  will  be  loss  of 
sensation  of  pain  and  temperature. 

(b)  Medullary  Tumours.  In  these  cases  there  will  be  similar  signs  but 
without  the  radiating  pains  from  involvement  of  nerve-roots. 

As  the  tumour  progresses  spastic  paralysis  involves  both  lower  limbs, 
but  sensation  is  seldom  completely  lost.  The  radiating  pains  and  gradual 
palsy  are  characteristic. 

Diagnosis.  The  slower  onset  and  spread  will  distinguish  from  haemor- 
rhage or  myelitis,  while  radiographs  will  exclude  disease  of  the  spine,  which 
may  by  pressure  cause  similar  signs.  Syphilis  must  always  be  excluded  by 
the  serum  reaction  and  administration  of  iodides.  The  position  of  the 
tumour  is  mapped  out  by  considering  the  relation  of  the  spines  of  the 
vertebrae  to  the  nerve-roots  and  of  the  latter  to  the  cutaneous  and  muscular 
regions  affected. 

Treatment.  Laminectomy  and  removal  of  the  tumour  have  given  brilliant 
results  in  suitable  cases,  i.e.  in  non-invading  growths  of  the  meninges. 
Where  the  growth  is  infiltrating  division  of  the  nerve-roots  may  relieve 
the  pain. 

{<■)  Syringomyelia,  a  gliomatous  formation  in  the  grey  matter  of  the  cord 
around  the  central  canal,  with  cavitation,  usually  in  the  cervical  region, 
is  of  importance  as  likely  to  be  confused  with  injuries  to  nerves  from  cervical 
ribs.  The  signs  are  loss  of  appreciation  of  heat,  cold  and  pain,  while  touch 
is  preserved  owing  to  escape  of  the  posterior  columns  :  muscular  paralysis 
and  wasting  of  the  lower-segment  type  in  the  arms  and  trophic  degenera- 
tions of  joints  are  found.  Diagnosis  is  considered  under  Affections  of 
Nerves. 


I  HAPTEB  XVI 

AFFECTIONS  OF  THE  PERIPHERAL  NERVES 

I  reneral  Considerations  :  Examination  :  Injuries  of  Nerves  :  Pseudo-neuromas  : 
Recovery  after  Injuries  :  Treatment  :  Neuritis  :  Neuralgia  :  Tumours  of  Nerves  : 
Special  Nerves  :  The  Cranial  Nerves  :  Trigeminal  Neuralgia  :  Operations  : 
The  Facial  Nerve  :  Operations  :  The  Cervical  Plexus  :  The  Brachial  Plexus  : 
The  Musculo-spiral,  Ulnar,  and  Median  Nerves  :  The  Cauda  Equina  :  The 
Sciatic  Nerve  :  Sciatica. 

General  Considerations.  Most  of  the  larger  peripheral  nerves  contain 
both  motor-fibres  to  the  muscles  and  sensory-fibres  from  the  skin  and 
deeper  structures  ;  a  few  of  the  larger  nerves  are  purely  sensory,  e.g.  the 
radial  and  long  saphenous  nerves.  The  investigations  of  Head  and  Sherren 
show  pretty  clearly  that  at  least  three  varieties  of  sensory  impulses  are 
conveyed  along  the  afferent  nerves  to  the  cord  and  brain,  possibly  along 
different  sorts  of  fibres  which  course  both  in  deep  and  superficial  nerves. 
These  impulses  alter  in  arrangement  as  they  reach  the  spinal  cord 
(pp.  640,  641). 

The  sensations  conducted  in  these  various  systems  are  : 

(1)  Sensation  of  deep  touch  or  'pressure,  which  remains  after  all  the 
cutaneous  nerves  are  divided.  Thus  if  the  median,  ulnar,  and  radial  nerves 
are  divided  at  the  wrist,  the  patient  can  still  appreciate  pressure  made 
firmly  on  the  hand  or  fingers  as  well  as  alterations  in  the  position  of  the 
fingers  (muscular  sense),  but  if  the  tendons  are  divided  as  well  this  form  of 
sensation  is  lost,  from  which  it  is  inferred  that  sensations  of  pressure  and 
muscular  sense  ("  deep  pressure  ")  are  conveyed  in  nerves  running  along 
the  tendons  and  muscles,  travelling  from  there  with  the  motor-nerves. 

(2)  Crude  sensation  of  rather  unpleasant  nature  with  little  power  of 
localization  of  the  stimulus  known  as  "  protnpafhic  scits(itit>)i,"  which 
implies  power  to  notice  pin-pricks  but  not  light  touch  with  cotton-wool. 
The  sensation  is  of  a  tingling  nature,  not  localized  with  exactness  but 
radiating  over  a  large  area.  By  this  form  of  sensation  only  extreme  degrees 
of  heat  and  cold  are  appreciated,  i.e.  when  over  45°  C.  or  under  20°  C. 
This  form  of  sensation  is  conveyed  by  the  cutaneous  nerves  but  does  not 
correspond  to  their  anatomical  distribution,  being  much  wider  and  with 
overlapping  of  the  distributions  of  neighbouring  nerves. 

(3)  High-grade,  refined,  critical  appreciation  of  stimuli  known  as  "  epi- 
critic  sensation,"  which  is  characterized  by  appreciation  of  light  touch 
with  cotton-wool,  power  to  estimate  compass-points  separately  at  small 
listances  (varying  from  three  inches  on  the  back  to  a  quarter  of  an  inch  on 

651 


VARIETIES  OF  SENSATION 


655 


the  finger-tip),  and  power  to  discriminate  between  small  differences  of 
temperature,  viz.  between  22°  C.  and  38°  C,  as  well  as  the  more  extreme 
ranees.  The  areas  of  distribution  of  these  nerve-fibres  is  well  defined  and 
regular,  corresponding  with  the  anatomical  distribution  of  cutaneous  nerves. 
The  complete  distribution  of  a  nerve  can  only  be  estimated  by  examining 
cases  where  all  the  other  nerves  of  supply  to  the  extremity  have  been 
divided,  in  which  case  the  remaining  epicritic  sensation  "  residual  sensa- 
tion "'  corresponds  to  the  anatomical  distribution,  but  the  area  of  proto- 


Fig.  249.     Ulnar  paralysis,  Bhowing  wasting  of  the  interossei  and  flexion 
of  the  third  and  fourth  fingers. 


pathic  residual  sensation  is  much  larger  than  this  and  the  deep  sensibility 
is  unaltered  unless  the  tendons  are  divided  as  well.    (Figs.  261,  202.) 

Examination  of  Cases  suffering  from  Lesions  of  Nerves.  This 
includes  a  general  examination  of  the  part  supplied  by  the  nerve  affected, 
of  the  nerve  throughout  its  course,  from  its  origin  in  the  cord,  and 
examination  of  the  sensory  and  motor  functions  of  the  nerve. 

(1)  General  Examination.  The  position  of  a  limb  due  to  paralysis  may 
give  a  very  shrewd  idea  of  the  nature  of  the  lesion,  e.g.  "  dropped  wrist  " 
from  musculo-spiral  lesion,  equino-varus  of  the  foot  from  lesions  of  the 


656  A  TEXTBOOK  OF  SURGERY 

external  popliteal  nerve,  "complete  claw-hand"  from  lesion  of  tin-  first 
dorsal  root,  &c.    (Fig.  249.) 

Scars  or  wounds  iu  the  course  of  the  nerve,  deformities  from  fractures 
or  of  developmental  nature,  as  cervical  rib,  may  throw  light  on  the 
nature  of  the  lesion,  while  whitlows  or  trophic  ulcers  show  severe  interference 
with  nerves. 

(2)  Motor  Functions.  The  muscles  should  be  examined,  handled,  and 
the  circumference  of  the  limb  measured  to  detect  wasting,  and  contracture 
of  the  unaffected  opposing  muscles.  Power  of  voluntary  action  should 
be  tested  ;  an  exact  anatomical  knowledge  of  the  action  of  various  muscles 
is  needed  to  do  this  satisfactorily. 

The  electrical  reactions  of  the  muscles  should  always  be  tested,  both  to 
constant  and  induced  currents ;  for  children  an  anaesthetic  will  often  be 
advisable,  and  both  sides  are  tested. 

It  is  best  to  connnence  with  an  induced  current  strong  enough  to  produce 
slight  contraction  of  the  forearm-muscles  of  the  observer.  A  good  light 
is  needed  to  see  if  contraction  takes  place,  and  when  this  results  from 
stimulation  with  the  interrupted  current  the  muscle  may  be  regarded  as 
normal  as  regards  its  innervation.  Where  there  is  no  response  to  the 
induced  current  the  continuous  should  be  tried.  On  stimulating  with 
the  constant  current  the  muscle  contracts  only  on  making  or  breaking  the 
circuit,  and  if  normal,  with  a  single  smart  twitch,  which  is  obtained  on 
making  the  circuit  with  less  current  if  the  cathode  be  used  as  the  point  of 
excitation  :  if  the  anode  be  the  point  of  excitation  the  reverse  obtains,  for 
on  breaking  the  circuit  contraction  is  obtained  with  less  current  at  the 
anode  than  at  the  cathode.  When  the  motor-nerve  is  out  of  action  the 
response  of  the  muscle  alters.  In  the  first  place,  a  strong  current  is  needed 
to  get  any  response  at  all,  and  this,  instead  of  being  a  quick  short  twitch, 
is  a  prolonged,  sluggish  heave  of  the  muscle  lasting  two  or  three  seconds. 
The  phenomena  of  "  polar  reversal  "  are  also  noted,  viz.  that  the  response, 
on  making  the  circuit,  is  obtained  with  less  current  if  the  anode  be  the  point 
of  stimulation  and  vice  versa  on  braking  the  circuit.  When  a  muscle 
fails  to  contract  on  stimulation  with  induced  current  and  gives  the  above- 
described  sluggish  response  and  "  reversal  of  polar  phenomena,"  it  is  said 
that  the  "  reaction  of  degeneration  "  (R.D.)  is  present.  This  reaction  is 
considered  to  mean  that  the  muscle  is  cut  off  from  the  action  of  its 
motor-nerve  cells  on  the  anterior  horn  of  the  spinal  cord,  e.g.  after  section 
of  a  nerve  or  destruction  of  the  motor-nerve  cell  by  poliomyelitis,  &c. 

The  reaction  does  not  develop  for  about  fourteen  days  after  the  muscle 
is  cut  off  in  this  manner.  WThere  the  nerve  is  injured,  but  incompletely 
divided,  the  two  following  reactions  are  described  (Sherren)  : 

(a)  In  slight  instances  the  muscle  is  paralysed  as  regards  voluntary 
action  but  reacts  to  the  induced  current. 

(b)  The  muscle  ceases  to  respond  to  the  induced  current  but  responds 
to  a  weaker  constant  current  than  usual,  and  with  a  sharp  twitch  and  not 
the  usual  sluggish  contraction  of  degeneration. 


INJURIES  OF  NERVES  057 

(3)  Examination  of  Sensation.  To  test  for  epicritic  sensation  small 
wisps  of  very  soft  cotton-wool  or  soft  camel-hair  brushes  are  used,  and  care 
is  taken  to  make  the  touch  very  light  or  sensations  of  "  pressure  "  may  be 
evoked  ;  moreover,  on  hairy  situations  light  touch  may  be  simulated  by 
the  hairs  being  moved  and  causing  protopathic  sensations  to  be  developed, 
so  that  in  doubtful  cases  it  will  be  necessary  to  shave  the  surface  before 
examination.  For  purposes  of  research,  testing  the  appreciation  of  compass- 
points  or  minor  grades  of  temperature  will  be  necessary.  To  test  for  proto- 
pathic sensation  a  sharp  needle  is  employed,  taking  care  not  to  press  hard, 
or  sensations  of  "  deep  touch  "  (pressure)  may  be  caused.  The  sensation 
of  "  deep  touch  "  (pressure)  is  investigated  by  firm  pressure  of  some  blunt 
object,  such  as  the  end  of  an  uncut  pencil.  The  patient  investigated  should 
be  in  a  quiet  place  with  the  eyes  closed,  and  instructed  to  answer  only 
when  the  sensation  under  investigation,  whether  of  touch,  pain  or  pressure, 
is  felt :  it  is  a  great  mistake  to  keep  inquiring  whether  the  patient  feels 
the  sensation.  In  all  cases  of  injury  where  there  is  considerable  chance  of 
nerves  being  divided,  e.g.  in  wounds  about  the  wrist,  investigation  of  the 
nerves  should  always  be  made  before  the  lesion  is  treated  by  suture,  &c, 
since  the  results  of  primary  suture  of  nerves  are  far  superior  to  those  resulting 
from  later  treatment. 

Injuries  of  Nerves.  Nerves  may  be  divided  in  open  wounds  or  affected 
subcutaneously.  In  either  case  the  division  of  the  nerve  may  be  complete 
or  incomplete. 

Subcutaneous  lesions  are  due  to  pressure  or  traction,  and  may  be  caused 
by  sudden  violence,  e.g.  complicating  fractures,  dislocation,  or  wrenches  of 
limbs,  or  arise  slowly  from  the  pressure  of  tumour  or  other  slowly  developing 
swelling  such  as  callus,  cervical  ribs,  &c.  Sherren  further  divides  lesions 
of  nerves  into  anatomical,  where  there  is  some  macroscopic  lesion  of  the 
nerve  (as  seen  on  exploration),  and  phynologica1,  in  which  the  nerve  appears 
normal  on  inspection  but  its  functions  are  interrupted.  A  few  examples 
will  help  to  explain  these  differences. 

(1)  Involvement  of  nerves  in  open  wounds  may  be  accidental,  as  in 
wounds  about  the  wrist,  or  surgical  in  the  case  of  the  facial,  spinal  accessory, 
lower  dorsal,  and  lumbar  nerves  in  operations  about  the  mastoid,  for  glands 
of  the  neck,  in  abdominal  and  renal  operations  respectively  ;  and  they 
may  generally  be  avoided  by  suitable  technique,  since  their  division  leads 
to  paralysis  of  important  muscles  and  sometimes  to  areas  of  hyperesthesia 
from  destruction  of  epicritic  sensation  over  the  area  supplied,  since  the  skin 
when  supplied  only  by  protopathic  fibres  has  a  subjective,  raw,  unpleasant 
feeling. 

(2)  Pressure  effects  may  result  from  sudden    blows  on  the  nerve,  a 
paralysis  of  the  ulnar  following  a  blow  on  the  internal  condyle  of  the  humerus  ; 
or  prolonged  pressure,  as  in  the  "  crutch  palsy  "  affecting  the  musculo-spiral, 
or  pressure  of  callus,  which  often  affects  the  last-mentioned  nerve. 

(3)  Traction  injuries  are  due  to  overstretching,  and  usually  are  found 
in  the  brachial  plexus  or  some  part  of  this,  as  in  Erb's  palsy,  in  which 

i  42 


A  TEXTBOOK  OF  SURGERY 

the  tiftli  cervical  root  is  overstretched  by  strong  traction  of  the  bead  of 
the  foetus  to  the  opposite  side  (luring  parturition,  while  the  lower  part  of 
the  plexus  may  be  a  tie*  ted  by  prolonged  retention  of  the  arms  over  the 
head  during  anaesthesia.  These  injuries  are  commonly  physiological,  and 
will  be  considered  in  further  detail  under  individual  lesions  of  Nerves. 

R  ESULTS  of  Ix.jiRiEs  to  Nerves.  Anatomy.  At  the  site  of  a  complete 
division  the  aerve  retracts  slightly  and  there  is  exudation  into  the  end  of 
the  proximal  portion.  Later  fibrous  tissue  is  formed  in  this  free  end,  into 
which  prolongations  of  the  axis-cylinders  of  the  nerve-fibres,  which  are  cut 
across,  grow  down,  the  whole  forming  a  bulbous  mass  of  fibrous  tissue 
and  tortuously  coursing  axis-cylinders,  which  is  often  the  seat  of  much 
neuralgic  pain.     Below  the  site  of  division  descending  degeneration  takes 


Fig.  250.     Median  paralysis  ;   attempt  to  produce  opposition  of  the  thumb. 
Note  the  wasting  of  thenar  eminence. 

place,  commencing  in  about  a  week.  The  myelin-sheath  of  the  nerve  breaks 
up  into  fat  globules,  the  cells  of  the  neurilemma  proliferate  into  cellular 
cords,  the  axis-cylinders  becoming  disintegrated,  and  conduction  of  the 
nerves  ceases  to  take  place,  resulting  in  the  Reaction  of  Degeneration  of  the 
muscles.  Where  the  division  is  incomplete  minor  degrees  of  these  changes 
will  occur  in  the  parts  affected. 

Clinical  Effects  of  Nerve  Section  and  Division.  These  vary  with 
the  degree  to  which  the  nerve  is  divided,  i.e.  whether  complete  or  incomplete. 

(a)  In  case  of  complete  division  of  a  mixed  nerve,  whether  anatomical 
or  physiological,  the  following  changes  will  be  noted  : 

(1)  1  he  position  of  the  limb  or  digits  may  be  characteristic,  as  in  Erb's 
palsy  or  lesions  of  the  musculo-spiral  and  ulnar  nerves  (Fig.  249). 

(2)  Motor  paralysis  must  be  looked  for  carefully,  not  merely  noting 
movements  of  any  particular  nature,  e.g.  flexion  or  extension  of  a 
joint,  hut  observing  the  action  of  individual  muscles.     Thus  in  paralysis 


CLINICAL  SIGNS  OF  NERVE  LESIONS  659 

of  the  muscles  of  the  thumb  supplied  by  the  median  nerve  it  will  be  possible 
to  oppose  the  thumb  and  abduct  it  after  a  fashion,  though  the  opponens  and 
abductor  are  paralysed,  but  true  opposition  by  the  opponens,  which  is  a 
circumduction  of  the  thumb  in  the  ulnar  direction,  and  abduction,  which  is 
a  movement  at  right  angles  to  the  plane  of  the  palm  and  due  to  the  action 
of  the  abductor  pollicis,  will  be  lost  (Fig.  250).  After  fourteen  days  the 
reaction  of  degeneration  will  be  detected  in  the  paralysed  muscles,  and 
later  wasting  of  these  and  contracture  of  the  unopposed  normal  muscles 
(unless  careful  treatment  be  adopted)  wjll  result,  producing  such  charac- 
teristic deformities  as  the  semi-claw  hand  of  ulnar  paralysis  or  the  complete 
claw  of  inner-cord  lesions. 

(3)  Changes  in  the  Skin  and  Nails.  The  epidermis  is  thickened  and 
heaped  up  over  the  area  in  which  both  epicritic  and  protopathic  sensations 
are  lost ;  if  the  epidermis  be  soaked  off  the  underlying  epidermis  is  soft 
and  thin,  the  surface  appearing  red  and  smooth.  Later  the  digits  taper 
to  their  extremities,  the  skin  being  smooth  and  red  or  blue  and  the  pulps 
wasted,  but  the  integument  is  not  so  shiny  as  in  cases  of  true  "  glossy  skin  " 
which  are  due  to  partial  and  irritative  lesions  of  nerves.  The  nails  become 
brittle,  lose  their  gloss,  and  are  ridged.  Sweating  is  diminished  over  the 
affected  area.  As  long  as  the  skin  is  insensitive  to  protopathic  sensation 
it  is  liable  to  damage  by  hot  water,  cold,  and  other  injuries  (which  are  not 
perceived  owing  to  the  lack  of  feeling  in  the  part),  and  blisters  and  whitlows 
are  common,  which  may  destroy  the  terminal  phalanx  or  more  of  a  digit. 
In  the  area  where  protopathic  sensation  is  lost  the  finger  bleeds  more  freely 
when  pricked  and  the  mark  of  a  prick  lasts  for  several  hours  (vasomotor 
changes). 

(4)  Sensory  Changes.  These  are  confined  to  loss  of  protopathic  and 
epicritic  sensation  unless  the  tendons  are  also  divided  to  a  considerable 
extent,  in  which  case  deep  sensibility  will  also  be  affected.  The  relation 
of  epicritic  to  protopathic  loss  varies  with  the  position  of  the  lesion  in  the 
nerve.  When  the  lesion  is  low  down  the  nerve  near  its  periphery,  e.g.  in 
the  ulna  at  the  wrist,  the  area  of  protopathic  loss  is  always  much  less  than 
that  of  epicritic  loss,  varying  in  amount  in  different  subjects,  the  epicritic 
loss  being  constant  and  corresponding  with  the  anatomical  distribution  of 
the  nerve.  The  area  in  which  protopathic  sensations  alone  are  felt  is 
sometimes  called  the  "  intermediate  zone."  Where  the  posterior  roots 
are  divided  in  the  spinal  canal  the  area  of  loss  of  protopathic  sensation  is 
much  larger  than  that  of  epicritic  sensation  ;  in  other  words,  there  is  an 
overlapping  of  the  epicritic  distribution  of  the  posterior  roots  and  of  the 
protopathic  distribution  of  peripheral  nerves.  In  some  instances  the  proto- 
pathic and  epicritic  distributions  correspond  closely  ;  thus,  if  the  externa] 
popliteal  nerve  be  divided  the  areas  of  epicritic  and  protopathic  loss  nearly 
correspond,  for  the  external  popliteal  nerve  consists  chiefly  of  the  fifth 
lumbar  root.  Where  a  nerve  is  not  the  exclusive  supply  of  the  area  of  skin 
its  division  will  cause  no  loss  of  sensation  that  can  be  appreciated,  e.g. 
if  the  radial  nerve  be  divided  in  the  upper  part  of  the  forearm.     On  the 


A  TEXTBOOK  OF  SURGERY 

whole,  the  higher  the  lesion  is  in  the  nerve  the  more  the  area  of  protopathic 
tends  to  equal  that  of  epicritic  loss,  till  finally,  when  the  posterior  root  is 
divided,  the  protopathic  loss  will  be  the  greater. 

(6)  Clinical  Effects  of  Incomplete  Division  of  Nerves.  In  these  cases  the 
interruption  in  the  nerve  does  not  cause  degeneration  of  the  whole  of  the 
peripheral  portion.  Anatomical  and  physiological  forms  are  found  in  these 
cases  also.  As  much  as  one-third  of  a  nerve  may  be  divided  without  causing 
any  save  the  most  transient  alteration  in  motion  or  sensation  unless  the 
seet  Li  m  be  made  near  a  branch  or  where  a  nerve  consists  really  of  two  separate 
nerves  bound  together,  as  in  the  case  of  the  sciatic.  In  other  words,  the 
fibres  of  nerves  are  not  arranged  in  definite  order  of  their  distribution  at 
the  periphery.  These  facts  have  been  noted  where  nerves  were  partially 
divided  in  operations  for  anastomosing  nerves. 

Where  symptoms  occur  from  partial  division  motion  is  less  affected  than 
sensation. 

(1)  Motor  effects  vaiy  from  no  paralysis  to  complete  palsy  of  all  muscles 
supplied,  and  the  electrical  reaction  is  either  no  change  or  loss  of  response 
to  induced  current  and  a  sharp  twitch  to  a  weaker  constant  current  than 
is  usually  needed  to  provoke  contraction  (Sherren). 

(2)  Sensation.     Epicritic  sensation  is  chiefly  affected,  most  usually  being 
completely  lost  over  the  area  in  question,  or,  although  the  area  be  not 
insensitive  to  light  touch,  the  skin  feels  different  to  the  surrounding  parts 
when  stroked  with  cotton-wool.     In  some  cases  there  is  protopathic  loss 
as  well.     The  later  results,  especially  where  there  is  irritation,  as  by  involve- 
ment in  a  scar  or  irritation  by  a  foreign  body  such  as  a  bullet,  are  as  follows  : 
There  is  far  more  pain  than  in  cases  of  complete  division,  together  with 
trophic  changes  in  the  skin  and  nails.     This  condition  when  marked  is  known 
as  causalgia,  or  "  glossy  skin,"  and  the  changes  are  as  follows  :   The  skin 
over  the  affected  part  becomes  red  and  mottled,  shiny  as  if  varnished,  and 
very  tender.    The  subcutaneous  tissues  atrophy,  the  skin  fitting  tightly 
over  the  phalanges.     The  skin  sweats  freely  and  the  nails  grow  faster  than 
usual,  while  blisters  and  ulcers  are  common.     In  these  severe  cases  there 
is  usually  irritation  of  the  nerve  from  prolonged  suppuration  and  fibrosis 
or  from  the  imbedding  of  a  foreign  body  in  its  substance,  the  nerve  being 
in  a  condition  of  neuritis.     In  the  non-irritative  cases  the  changes  of  the 
skin  are  less  noticeable  unless  there  is  loss  of  protopathic  sensation,  in  which 
case  the  condition  may  resemble  that  found  in  cases  where  the  nerve  has 
been  completely  divided.     In  severe  cases  of  the  causalgic  type  the  con- 
stant pain  may  break  down  the  patient's  moral  stamina  and  render  him 
hysterical. 

Involvement  of  Nerves  in  Scar  Tissue.  This  may  follow  injuries 
or  operations,  and  may  be  associated  with  the  atrophic  changes  of  causalgia 
or  be  simply  subjective,  the  alteration  of  sensation  spreading  to  the  whole 
protopathic  distribution  of  the  nerve  involved,  there  being  no  loss  of  sensa- 
sion  but  tenderness  over  the  whole  area  ;  less  often  epicritic  sensation  may 
be  lost. 


DIAGNOSIS  OF  NERVE  LESIONS  661 

Amputation  Bulbs  (pseudo-neuromas).  These  may  be  regarded  as  a 
variety  of  irritation  of  nerves  from  scar-tissue,  consisting  as  they  do  of  a 
mass  of  fibrous  tissue  surrounding  newly  formed  axis-cylinders.  These 
bulbs  do  not  form  if  the  nerve  at  amputation  be  pulled  down,  divided  high 
up,  and  crushed.  The  symptoms  may  appear  many  years  after  an  amputa- 
tion, consisting  in  pain  referred  to  the  limb,  often  dependent  on  weather 
conditions,  and  tenderness  over  the  stump,  especially  from  pressure  on 
the  bulb. 

Diagnosis  of  Nerve  Injuries.  This  has  to  be  made  from  affections  of 
the  spinal  cord,  hysterical  manifestations,  and  other  contractures,  especially 
the  ischsemic  variety  (Volkmann). 

From  spinal-cord  lesions  the  grouping  of  the  affected  muscles  {see  Diagnosis 
of  Affections  of  the  Spinal  Cord),  the  fact  that  in  the  cord  conducting- tracts 
are  probably  affected,  so  that,  for  example,  in  addition  to  a  lower-segment 
lesion  of  the  arm  there  will  be  an  upper-segment  lesion  of  the  leg.  The 
different  grouping  of  afferent  impulses  in  the  cord  with  regard  to  heat,  cold, 
pain,  and  touch  will  render  diagnosis  fairly  simple  when  a  complete  examina- 
tion has  been  made,  but  an  injury  to  an  anterior  root  may  be  indistinguishable 
from  that  of  the  corresponding  anterior  horn-cells. 

Hysterical  affections  of  motion  and  sensation  are  distinguished  by 
following  in  their  distribution  no  possible  nerve  or  cord  lesions.  Thus 
anaesthesia  of  hysterical  origin  takes  the  form  of  an  area  of  stocking  or  glove 
shape  limited  above  by  a  circular  line  corresponding  to  no  nerve  distribution 
or  segment  of  the  spinal  cord  ;  moreover,  all  forms  of  sensation  are  lost 
at  the  same  line,  which  is  never  the  case  in  lesions  of  the  cord  or  nerves. 
Other  sensory  affections  are  often  present,  such  as  contraction  of  the  visual 
fields  specially  for  blue,  whereas  in  organic  disease  that  for  red  suffers 
most ;  anaesthesia  of  the  palate  is  a  common  sign  of  hysteria.  If  hysterical 
paralysis  be  present  this  will  be  of  the  flaccid  type  but  without  any  reaction  of 
degeneration  of  the  affected  muscles.  As,  however,  hysteria  not  infrequently 
complicates  organic  lesions  of  the  nervous  system,  care  is  needed  to  allocate 
to  each  condition  its  fair  share  in  the  production  of  the  disorder.  Ischaemic 
contracture  is  sometimes  mistaken  for  paralysis  and  contracture  following  on 
lesions  of  nerves,  but  there  is  no  reaction  of  degeneration  in  the  affected 
muscles ;  moreover,  the  contracted  muscles  are  hard  and  cordlike  and  the 
contracture  comes  on  rapidly  after  the  injury,  being  well  developed  in 
two  to  three  weeks,  while  contractures  from  nerve  lesions  take  months  to 
develop. 

Repair  and  Regeneration  of  Nerves.  Primary  union  of  nerves, 
i.e.  a  reunion  of  axis-cylinders,  myeline-sheath  and  neurilemma,  without 
preceding  degeneration  of  the  distal  part  of  the  nerve  and  the  associated 
alterations  in  motion  and  sensation,  never  occurs  ;  cases  reported  as  being 
of  this  nature  are  due  to  imperfect  investigation.  After  the  degeneration, 
already  mentioned  as  following  section,  has  taken  place,  regeneration  may 
(  ccur  if  the  divided  ends  are  in  apposition  or  are  brought  together  by  means 
of  sutures.     It  is  still  debated  as  to  whether  the  new  axis-cylinders  grow 


662  A  TEXTBOOK  OF  SURGERY 

down  into  tin*  distal  part  of  the  nerve  from  the  proximal  portion  01  whether 
they  arc  formed  in  the  cell-masses  of  the  peripheral  degenerating  portion, 
from  multiplication  of  these  cells.  In  any  ease,  unless  the  axis-cylinders 
of  the  upper  part  are  in  contact  with  the  lower  degenerating  portion  regene- 
ration of  any  practical  value  cannot  take  place.  The  formation  of  new 
axis-cylinders  in  the  distal  part  of  the  nerve  is  a  matter  of  considerable  time, 
and  it  may  be  two  or  three  years  before  complete  recovery  of  function 
takes  place,  though  the  practical  result  may  be  very  useful  after  a  much 
shorter  interval. 

Recovery  of  Function  after  Union  of  Divided  Nerves  (Sherren). 
(a)  After  primary  suturing  of  the  divided  nerve,  i.e.  suturing  at  once  or  as 
soon  as  the  reaction  of  degeneration  is  discovered. 

(1)  Sensation.  Protopathic  sensation  is  restored  first,  and  begins 
gradually  within  six  to  sixteen  weeks  after  union,  the  area  of  loss  of  sensation 
of  prick  gradually  diminishing  till  in  four  to  twelve  months  the  area  is 
completely  sensitive  to  protopathic  stimuli  (prick)  :  the  part  is  sensitive 
and  very  uncomfortable,  but  this  marks  a  stage  of  recovery,  and  when  this 
stage  is  complete  no  more  blisters  or  ulcers  form  on  the  area  affected. 
Recovery  of  epicritic  sensation  does  not  commence  till  that  for  protopathic 
sensation  is  re-established,  and  proceeds  gradually,  taking  from  twelve 
months  in  cases  of  primary  suture  at  the  wrist.  Where  suppuration  has 
taken  place  in  the  wound  or  secondary  suture  has  been  performed,  res- 
toration of  epicritic  sensation  will  be  much  delayed  or  remain  permanently 
deficient.  Even  where  appreciation  of  light  touch  is  perfect  recovery  is 
not  complete,  for  points  of  a  compass  may  not  be  appreciated  as  separate 
and  the  patient  may  notice  alterations  of  sensation  in  the  recovered  area  ; 
complete  recovery  will  take  at  least  two  years.  Epicritic  sensation 
recovers  more  rapidly  where  the  lesion  is  near  the  periphery,  while  the 
point  of  lesion  makes  no  difference  to  protopathic  recovery. 

(2)  Motor  power  is  recovered  more  rapidly  the  nearer  the  injury  is  to 
the  periphery.  Thus  if  the  ulnar  nerve  be  cut  at  the  wrist  recovery  may 
take  one  year,  but  if  divided  at  the  elbow  two  years  are  needed. 

The  prognosis  in  cases  of  primary  suture,  which  heals  by  first  intention, 
is  good,  but  if  suppuration  occurs  the  outlook  is  worse  both  for  rapidity 
and  completeness  of  the  result,  being  often  imperfect.  The  nearer  the  injury 
is  to  the  periphery  the  better  the  prognosis. 

{b)  After  secondary  suture  the  prognosis  is  less  good,  complete  recovery 
being  rare.  The  interval  between  suturing  and  the  commencement  of 
epicritic  recovery  is  twice  as  long  as  is  taken  in  cases  of  primary  suture, 
motor  recovery  is  also  less  rapid.  Incomplete  recovery  is  of  little  account 
in  the  case  of  lesions  of  the  musculo-spiral  nerve  or  external  popliteal  nerves, 
but  incomplete  recovery  of  the  median  or  ulnar  nerves  greatly  incapacitates 
the  patient  for  finer  work.  Secondary  suture  is  not  likely  to  be  of  much 
use  after  three  years  ;  up  to  this  time  there  is  a  prospect  of  recovery  of 
muscular  power  and  also  of  protopathic  sensation,  which  prevents  the 
formation  of  trophic  ulcers,  a  point  of  considerable  importance. 


TREATMENT  OF  NERVE  LESIONS  663 

Treatment  of  Injuries  to  Nerves.  This  will  vary  somewhat,  according 
as  the  injury  is  open  or  subcutaneous.  The  importance  of  early  diagnosis 
has  already  been  pointed  out,  since  the  results  of  immediate  or  primary 
suture  are  so  very  superior  to  those  where  suture  has  been  delayed  for  some 
weeks  or  months. 

(a)  Primary  Suture.  In  the  case  of  open  wounds  the  latter  should  be 
rendered  as  aseptic  as  possible,  and  enlarged  if  necessary  to  expose  fully 
the  site  of  division.  If  the  nerve  be  completely  divided  it  should  be  sutured 
with  fine,  absorbable  catgut  passed  on  ordinary  sewing-needles  with  no 
cutting  edge,  the  suture  being  passed  through  the  whole  thickness  of  the 
nerve  so  as  to  bring  the  ends  into  accurate  apposition  ;  if  lacerated,  the 
ends  should  be  trimmed  square.  Silk  should  not  be  used,  and  chromicized 
catgut,  which  will  last  about  fourteen  days,  is  the  best  material.  Having 
secured  accurate  apposition,  the  juncture  is  surrounded  with  Cargile  mem- 
brane (sterilized  peritoneum)  or  a  strip  of  fascia,  to  prevent  constriction  of 
the  union  by  formation  of  fibrous  tissue.  The  wound  should  be  drained 
for  twenty- four  hours  and  the  limb  placed  in  such  a  position  as  to  relax 
the  nerve,  e.g.  the  wrist  flexed,  for  median  or  ulnar  injuries.  Where  the 
division  is  incomplete  the  part  of  the  nerve  divided  should  be  closed  with 
similar  sutures. 

Where  the  injury  is  subcutaneous  it  will  often  be  uncertain  whether  the 
injury  is  anatomical  or  physiological,  complete  or  incomplete.  The  limb 
should  be  placed  in  a  position  to  relax  paralysed  muscles,  and  these  are 
massaged  daily  :  after  fourteen  days  the  electrical  reactions  are  tested, 
and  if  the  reaction  of  degeneration  be  present  the  nerve  should  be  explored, 
and  if  found  divided  it  should  be  sutured  as  already  described.  Where 
there  is  a  bulbous  swelling  at  the  point  of  lesion  this  should  be  excised 
and  the  ends  sutured  ;  where  no  macroscopical  change  is  noted  the  wound 
is  closed,  and  in  this  case,  or  where  the  division  is  obviously  incomplete, 
the  condition  should  be  treated  on  the  general  lines  laid  down  below.  Where 
the  nerve  affection  comes  on  some  time  after  injury  from  pressure  of  scar 
or  callus,  or  where,  though  incomplete,  the  condition  does  not  clear  up  in 
a  few  weeks,  the  site  of  lesion  should  be  explored  and  the  pressure  relieved. 

(b)  Secondary  Suture.  This  implies  operation  alter  the  reaction  of 
degeneration  in  the  distal  portion  of  the  nerve  is  well  established.  The 
time  after  injury  at  which  suturing  is  performed  influences  not  only  the 
time  taken  for  recovery  to  result  but  also  may  influence  the  completeness 
of  recovery,  since  the  overstretching  of  muscles  and  consequent  deformity 
are  greater,  the  longer  the  muscles  are  left  paralysed.  Where  there  is  no 
response  to  the  constant  current  the  prospect  of  recovery  of  muscular 
power  is  small,  but  from  the  point  of  view  of  sensation,  secondary  suture 
is  worth  doing  even  late,  especially  if  trophic  ulcers  are  present,  for  there 
is  always  a  fair  prospect  of  protopathic  recovery,  and  when  this  occurs  the 
ulcers  heal  up.  The  operation  involves  a  careful  and  often  tedious  dissec- 
tion to  find  the  divided  ends,  the  atrophic  distal  part  being  especially 
difficult  to  find. 


664 


A  TEXTBOOK  OF  SURGERY 


Bulbous  extremities  are  excised  and  the  freshened  ends  united  with  fine, 
partially  chromicized  catgut  as  before. 

Treatment  of  Irritative  Lesions  and  End  Bulbs.  Where  there  are 
symptoms  of  incomplete  and  irritative  lesion  (causalgia)  the  nerve  should 
be  exposed,  the  damaged  part  excised,  and  end-to-end  anastomosis  is 
performed  :  for  small  sensory  nerves  where  anastomosis  is  almost  impossible 
the  scar  should  be  removed  and  the  nerve  dissected  out  high  up  and  excised. 
End-bulbs  in  amputation-stumps,  if  painful,  should  be  exposed  and 
it'ii loved  with  a  couple  of  inches  of  normal  nerve,  crushing  the  end.  Should 
recurrence  of  pain  take  place,  then  posterior  roots  corresponding  to  the 
nerve  must  be  divided  inside  the  dura  mater. 

Treatment  where  the  Divided  Ends  will  not  meet  and  to 
reinforce  Paralysed  Nerves.     There  are  several  methods  possible  : 

(1)  Shortening  the  bone  of  the  limb  to  admit  of  approximation  of  the 
ends  of  the  nerve.     The  only  place  where  this  may  be  suitable  is  the  humerus 

in  case  of  musculo-spiral  paralysis 
from  involvement  in  fractures  of 
this  bone,  especially  where  non- 
union is  present,  and  it  is  neces- 
sary to  remove  bone  in  any  case. 

(2)  A  path  is  provided  along 
which  axis-cylinders  may  grow 
down  from  the  proximal  to  the 
distal  part  of  the  nerve  in  the 
following  ways  : 

(a)  By  placing  strands  of  cat- 
gut or  a  decalcified  bone  tube  or 
a  portion  of  nerve  from  another 
animal  between  the  divided  ends  : 
the  results  are  poor. 
(b)  Nerve-grafting  or  transplantation,  i.e.  placing  a  piece  of  human 
nerve  of  suitable  size  and  length  between  the  ends  and  suturing  in  position. 
The  radial  nerve  may  be  used  or  a  nerve  from  a  cadaver  removed  with  all 
aseptic  precautions.  This  method  as  applied  to  the  musculo-spiral  nerve 
has  proved  satisfactory  and  is  to  be  recommended. 

(3)  Nerve-anastomosis,  i.e.  uniting  the  peripheral  end  of  a  divided  or 
paralysed  nerve  with  some  other  nerve  in  the  neighbourhood.  Several 
methods  have  been  devised,  differing  in  the  amount  of  reinforcing  and 
injured  nerve  which  are  united,  and  are  suitable  for  different  conditions. 
When  the  reinforcing  nerve  is  completely  divided  the  anastomosis  is  called 
complete  central;  when  'partly  divided,  partial  central  anastomosis; 
similarly,  if  all  the  peripheral  part  is  anastomosed  with  the  reinforcing 
nerve  the  anastomosis  is  called  complete  peripheral,  if  only  part,  partial 
peripheral. 

(1)  Complete  central  anastomosis,  since  it  will  destroy  the  functions  of 
the  reinforcing  nerve,  is  generally  contra-indicated. 


Fig.  251.     Nerve  anastomosis.     A,  Partial  cen- 
tral    and     complete     peripheral     anastomosis. 
B,    Partial     central     and     partial     peripheral 
anastomosis. 


NEURITIS  665 

(2)  Complete  peripheral  with  partial  central  is  the  method  of  choice  in 
cases  of  complete  division  of  a  nerve  when  union  by  suture  is  not  possible, 
the  upper  end  of  the  distal  portion  being  implanted  into  a  transverse  slit 
passing  one-third  of  the  way  through  the  reinforcing  nerve,  or  a  flap  of 
this  nerve  of  similar  amount  is  turned  up  and  anastomosed  (Fig.  251a). 

(3)  Where  the  affected  nerve  is  not  completely  paralysed,  e.g.  in  cases 
of  infantile  paralysis,  partial  peripheral  and  partial  central  anastomosis  is 
the  method  of  choice  ;  a  flap  of  one-third  of  the  distal  part  of  the  divided 
or  of  paralysed  nerve  is  united  to  a  similar  partial  flap  of  the  reinforcing 
nerve.  It  cannot  be  right  to  divide  entirely  any  nerve  of  importance 
unless  its  function  is  completely  in  abeyance  (Fig.  251b). 

General  and  After-treatment  of  Cases  of  Injury  and  Paralysis 
of  Nerves.  Whether  suturing  has  been  performed  or  not,  the  paralysed 
muscles  must  be  carefully  treated  to  prevent  overstretching  and  maintain 
their  nutrition.  The  limb  is  arranged  on  a  splint  to  maintain  the  affected 
muscles  in  a  relaxed  position.  Thus  in  cases  of  musculo-spiral  paralysis 
the  wrist  and  metacarpals  are  kept  hyper- extended  ;  in  cases  of  injury  to 
the  external  popliteal  nerve  a  night-shoe  is  worn,  and  by  day  a  walking 
instrument  with  uplifting  toe-spring  and  varus  T-strap  to  prevent  the  varus 
deformity.  The  nutrition  of  the  muscles  is  maintained  by  daily  massage. 
Electrical  stimulation  with  the  sinusoidal  current  may  also  be  used,  though 
the  effect  of  this  is  less  than  of  massage.  Care  is  needed  to  protect  insen- 
sitive parts  from  heat  and  cold. 

Inflammations  of  Nerves  (neuritis).  (1)  Acute  neuritis  is  not  common 
but  may  follow  penetrating  wounds  with  suppuration  or  lodgment  of  foreign 
bodies  in  a  nerve,  and  clinically  presents  the  characters  described  under 
the  more  severe  results  of  incomplete  division  of  a  nerve,  viz.  causalgia, 
and  may  occur  with  or  without  paralysis  of  muscles. 

Treatment  consists  in  cleaning  the  wound,  removing  foreign  bodies, 
and  when  healed,  if  symptoms  pointing  to  irritative,  incomplete  division 
persist,  in  exploring  and  removing  the  damaged  portion  of  the  nerve,  suturing 
or  anastomosing  as  suits  the  position  of  the  lesion. 

(2)  Subacute  and  chronic  neuritis  is  more  common,  and  may  be  due 
to  various  causes  : 

(a)  Cold,  as  in  ordinary  facial  paralysis  (Bell's  palsy). 

(b)  Injuries  of  the  subcutaneous  variety  with  effusion  into  the  nerve- 
sheath,  e.g.  due  to  pressure  from  callus  (described  above). 

(c)  From  pressure  due  to  disease  of  neighbouring  parts,  as  facial  paralysis 
consequent  on  mastoid  disease,  pressure  of  tumours  and  aneurysms,  e.g. 
laryngeal  paralysis  from  aortic  aneurysm. 

(d)  Infective  disease,  whether  as  the  result  of  circulating  toxines  or 
local  action  of  diffused  infective  organisms,  as  in  diphtheria,  leprosy,  enteric, 
scarlet  fever,  malaria,  beri-beri,  and  possibly  rheumatism. 

(e)  Various  toxic  substances  introduced  from  without,  such  as  alcohol, 
arsenic,  lead,  carbon-bisulphide,  &c. 

(/)  Debilitating  condition  and  auto-intoxications,  as  phthisis,  cancer, 


A  TEXTBOOK  OF  SURGERY 

anamiia.  renal  disease,  diabetes.  The  first  three  groups  cause  local  neuritis  ; 
the  last  conditions  lead  to  disseminated  neuritis,  which  may  be  general  but 
often  picks  out  certain  "  nerves  of  election."  as  those  of  the  palate  and 
diaphragm  in  diphtheria,  the  optic  nerve  and  antebrachial  muscles  (wrist- 
drop) in  lead-poisoning,  the  legs  in  alcohol  (foot-drop). 

Anatomy.  The  condition  is  at  first  an  inflammation  of  the  connective- 
tissue  sheaths  around  bundles  of  nerve-fibres,  and  in  congestion  of  the  neuri- 
lemma later  there  may  be  proliferation  of  neurilemma,  degeneration  of 
axis-cylinders  in  the  peripheral  part  ;  in  some  instances  this  is  the  com- 
mencement of  the  disease. 

Signs.  Pain  referred  to  the  distribution  of  the  nerve,  if  sensory,  and 
tenderness  over  its  course  ;  in  some  instances  the  thickened  nerve  may  be 
distinctly  palpable  ;  then  changes  in  the  sensation  of  the  skin  supplied  with 
paralysis  and  wasting  of  the  muscles  ;  later  trophic  changes  in  the  skin, 
which  assumes  the  atrophic  "  glossy  "  character,  while  bedsores  are  likely 
to  appear. 

Treatment.  For  neuritis  of  local  origin  removal  of  the  cause  is  essential, 
as  detailed  in  the  treatment  of  incomplete  division  and  further  exemplified 
in  performing  mastoidectomy  in  case  of  facial  paralysis  due  to  middle-ear 
disease.  Removal  of  the  cause  is  also  essential  in  the  toxic  forms,  such 
as  those  due  to  alcohol,  lead,  arsenic,  &c. 

The  symptomatic  treatment  is  directed  to  the  paralyses,  sensory  dis- 
turbances, and  trophic  disorders  ;  paralysed  muscles  are  kept  relaxed  and 
in  as  good  condition  as  possible  by  daily  massage  and  electrical  treatment. 
Bedsores  are  prevented  if  possible,  and  are  treated  as  described  {see  Ulcers). 

For  the  pain  many  treatments  are  used.  Local  applications  such  as 
massage,  rubbing  with  liniment  of  camphor  or  aconite,  blistering  in  severe 
cases,  while  the  constant  or  high-frequency  electric  currents  may  afford 
relief. 

Of  drugs,  aspirin,  antipyrin,  and  pyramidon  are  recommended. 

Morphia  is  only  to  be  used  as  a  last  resource  and  when  the  condition 
is  likely  to  be  transitory,  lest  a  morphia  habit  be  developed. 

General  treatment,  as  iron  for  anaemia,  mercury  and  iodides,  especially 
with  a  syphilitic  history,  are  worth  a  trial. 

Various  surgical  measures  may  be  practised  in  inveterate  cases,  from 
simple  puncture  of  the  offending  nerve  with  a  needle  (acupuncture)  to 
resection  of  parts  of  a  sensory  nerve  or  section  of  the  posterior  nerve-roots 
passing  through  such  intermediate  forms  of  treatment,  as  injection  of  alcohol 
or  osmic  acid,  stretching  the  nerve,  &c. 

Neuralgia.  This  somewhat  vague  term,  meaning  pain  in  a  nerve,  is 
often  used  as  synonymous  with  neuritis ;  for  an  inflamed  nerve,  if  sensory, 
will  be  painful.  The  term  is  also  applied  to  various  referred  pains,  generally 
when  diagnosis  is  at  fault,  and  is  popularly  used  in  a  similar  manner  for 
any  pain  the  cause  of  which  is  not  understood  by  the  patient,  especially 
when  the  affection  is  about  the  head,  whether  due  to  eye-strain  from 
astigmatism  or  hypermetropia,  swelling  of  the  turbinates,  or  disease  of  the 


NEURALGIA  667 

antrum  and  frontal  sinus.  When  all  known  causes  are  eliminated  there 
remain  a  group  of  cases  where  the  painful  sensation  is  referred  to  the  course 
of  some  nerve  without  any  lesion  being  discoverable  there  even  on  micro- 
scopical examination.  Of  these  conditions  the  best  known  is  trigeminal 
neuralgia.     The  characteristics  of  neuralgia  are  : 

(1)  The  pain  is  paroxysmal,  the  attacks  being  of  varying  duration  with 
periods  of  remission. 

(2)  The  area  of  distribution  of  the  nerve  is  hypersesthetic,  especially  at 
certain  points. 

(3)  The  skin  may  be  flushed  or  even  cedematous,  and  the  hair  may  turn 
colour  or  drop  out  over  the  area  of  the  affected  nerve. 

(4)  Spasms  of  the  muscles  in  the  affected  area  may  be  noted. 

The  causes  are  most  uncertain.  Malaria,  gout,  rheumatism,  anaemia, 
worry,  lead,  and  mercury  are  all  made  responsible,  but  since  most  of  these 
may  be  the  cause  of  a  definite  neuritis,  it  must  be  questioned  if  they  are 
ever  the  causes  of  true  neuralgia.  It  is  better  to  admit  at  once  that  we 
have  at  present  no  idea  of  the  cause  of  neuralgia. 

Diagnosis.  Before  labelling  a  case  as  one  of  neuralgia  every  possible 
cause  of  neuritis  should  be  excluded,  but  in  addition  the  paroxysmal 
character  of  neuralgia  differs  from  the  constant  pain  of  neuritis.  Next, 
obscure  conditions  causing  pain  must  be  eliminated.  In  the  head  the  eye 
must  be  examined  critically  for  astigmatism,  iritis,  glaucoma  ;  the  nose  for 
deviations  of  the  septum,  enlarged  turbinates,  and  sinus  suppuration  ;  the 
teeth  for  caries  or  alveolar  abscess.  In  the  limbs  affections  of  joints  ; 
in  the  arm  cervical  ribs  ;  in  the  trunk  spinal  caries,  tumours,  aneurysms  ; 
in  the  leg  flat-foot,  metatarsalgia,  painful  spur  on  the  os  calcis,  etc. — must 
all  be  excluded.  Finally,  the  onset  of  acute  disease,  such  as  enteric  fever, 
or  the  commencement  of  an  attack  of  herpes  zoster  must  be  considered. 

Treatment.  Having  excluded  and  treated  all  causes  of  false  neuralgia, 
there  remain  drug,  electrical,  and  operative  measures. 

The  drugs  which  have  been  employed  embrace  most  of  the  pharmacopoeia 
and  include  :  general  tonics,  iron,  arsenic,  cod-liver  oil  ;  nerve  tonics, 
valerian  and  asafeetida,  which  may  work  wonders  in  fat  middl  s-aged  women 
about  the  menopause  ;  specifics,  quinine  in  malaria  and  antisyphilitic 
remedies :  nerve  sedatives,  aspirin,  pyramidon,  butyl-chloral  hydrate. 
Local  applications  of  menthol,  blistering,  or  the  actual  cautery  may  be 
useful. 

The  constant  electric  current  directed  along  the  course  of  the  nerve 
may  give  considerable  relief.  These  measures  suffice  for  minor  cases,  but 
when  severe,  operative  interference  will  be  admissible,  such  as  stretching 
or  removing  nerves,  cutting  posterior  nerve-roots,  or  removing  posterior 
root-ganglia. 

Tumours  of  Nerves.  True  neuromas  with  formation  of  new  fibres  and 
ga n url ion-cells  are  extremely  rare  and  have  been  found  originating  in  the 
sympathetic  ganglia  ;  other  tumours  formed  in  nerves  are  of  fibrous  nature 
and  may  be  localized  or  diffuse. 


A  TEXTBOOK  OF  SURGERY 

(1)  The  localized  neuio-fibroma  may  be  innocent  or  malignant,  i.e. 
fibroma  or  sarcoma  and  allied  conditions. 

The  slow-growing,  innocent  types  usually  only  cause  symptoms  late  in 
their  course  from  irritation  of  the  nerve,  possibly  with  alteration  in  sensa- 
tion in  the  area  supplied  and  weakness  of  muscles,  seldom  marked  paralysis. 
They  may  be  obvious  lumps  in  the  course  of  a  nerve,  and  noticed  by  the 
patient  or  only  discovered  by  the  practitioner  on  careful  examination  for 
obscure  pains.  Hence  the  importance  of  palpating  along  the  course  of  a 
nerve  when  the  pain  has  a  distinctly  radiating  distribution.  These  tumours 
when  discovered  are  solid  masses,  mobile  laterally  but  not  in  the  direction 
of  the  nerve-fibres. 

Treatment.  The  tumour  should  be  enucleated  from  the  nerve  with  as 
little  damage  as  possible  to  the  latter  ;  if  excision  of  part  of  the  nerve  be 
necessary,  a  nerve-graft  should  be  placed  in  the  gap  where  the  nerve  is  of 
importance.  A  wide  excision  will  be  needed  in  the  malignant,  rapidly 
growing  forms,  and  grafting  will  be  then  more  often  necessary. 

Another  form  is  the  "  painful  subcutaneous  nodule  "  (tubercula  dolorosa), 
which  are  often  multiple,  small  nodules  just  under  the  skin,  very  tender, 
and  only  showing  the  presence  of  nerve-fibrils  on  examination  by  special 
methods.     These  also  should  be  excised. 

(2)  Diffuse  N euro- fibromatosis  (von  Recklinghausen's  disease).  This 
condition  consists  in  an  increase  of  the  fibrous  tissue  of  the  nerve-sheaths  and 
elongation,  twisting,  and  tortuosity  of  the  nerve-fibres,  there  being  appa- 
rently no  formation  of  new  nerve-fibres.  These  tumours  are  often  multiple 
and  found  as  lumps  and  enlargements  in  the  course  of  nerves,  often  of  great 
size  and  complexity,  the  skin  over  them  being  hypertrophic  and  hanging 
in  pendulous  folds.  The  condition  is  then  very  similar  to  that  form  of 
diffuse  fibroma  known  as  "  molluscum  fibrosum  "  or  "  pachymadermato- 
coele,"  to  which  they  are  closely  akin.  These  formations  may  involve 
whole  limbs,  and  as  a  rule  pain  and  other  symptoms  are  slight.  These 
growths  are  most  usual  in  the  neck,  temple  and  scalp,  but  often  also  in 
the  trunk  and  limbs. 

Treatment.  This  is  often  unnecessary,  but  if  painful  or  inconvenient 
cosmetically  or  functionally  they  may  be  removed  by  dissection  if  not  too 
large  or  involving  important  nerves  ;  skin-grafting  will  often  be  needed 
after  their  removal. 

(3)  Amputation-neuromas  (pseudo-neuromas)  are  the  fibrous  masses 
forming  on  the  cut  ends  of.  nerves  after  amputation  or  in  the  course  of 
nerves  after  injuries,  and  have  already  been  discussed  (p.  6<>l ). 

AFFECTIONS   OF    SPECIAL   NERVES 

A.  Cranial  Nerves.  The  fifth,  seventh,  eleventh,  and  twelfth  are 
the  cranial  nerves  which  come  into  surgical  practice  ;  the  others  belong  rather 
to  general  medicine,  ophthalmology  and  neurology,  but  are  very  often 
important  in  diagnosis  and  demand  a  brief  notice  here. 

(1)  The  olfactory  nerve  may  be  the  seat  of  subjective  sensations  which 


THE  OPTIC  NERVE  669 

are  in  some  instances  the  "  aura  "  of  an  epileptic  fit ;  such  effects  are 
probably  due  to  affection  of  the  olfactory  tracts  or  higher  centres  rather  than 
of  the  olfactory  nerves.  Loss  of  smell  (anosmia)  may  be  due  to  injury 
of  the  olfactory  nerves  in  fracture  of  the  anterior  fossa  of  the  skull,  or  from 
inflammatory  lesions  associated  with  chronic  nasal  and  accessory  sinus 
suppuration,  or  following  influenza.  Note,  the  olfactory  sensations  include 
what  is  popularly  .known  as  "  taste,"  and  where  the  olfactory  sense  is 
impaired  the  patient  commonly  complains  of  "  loss  of  taste."  Tests  for 
the  olfactory  sense  should  be  made  with  aromatics  such  as  cloves  or  pepper- 
mint, and  not  with  irritating  bodies  such  as  ammonia,  which  stimulates 
the  nasal  branches  of  the  trigeminal  nerve. 
(2)  The  optic  nerve  may  be  affected  : 

(a)  As  it  spreads  out  in  the  retina,  in  renal  disease,  diabetes,  malaria, 
leukaemia,  retinitis  pigmentosa,  syphilis,  &c.  The  effect  on  vision  will 
depend  on  the  position  of  the  haemorrhages  and  patches  of  exudation  ; 
thus  if  the  yellow  spot,  where  acute  vision  is  situated,  be  affected,  sight 
will  be  greatly  impaired  ;  if  the  disease  is  more  peripheral,  as  in  retinitis 
pigmentosa,  the  visual  fields  will  be  contracted,  &c. 

(b)  In  the  nerve  itself,  as  by  injury  in  punctured  or  bullet  wounds  of  the 
orbit,  fracture  of  the  anterior  fossa,  in  orbital  cellulitis,  or  following  increase 
of  intracranial  pressure,  especially  from  cerebral  tumours,  less  often  from 
cerebral  abscess  or  sinus  thrombosis,  from  certain  poisons  as  lead,  tobacco, 
while  tabes  is  a  common  cause  of  optic  atrophy. 

The  affection  may  be  primarily  a  neuritis,  shown  by  swelling  of  the 
disc  measurable  with  the  ophthalmoscope,  hyperaemia,  and  puffiness  of  the 
disc  and  kinking  of  the  vessels  as  they  cross  the  edge  of  the  disc,  with 
dilatation  of  the  retinal  veins.  This  may  pass  on  to  secondary  atrophy, 
in  which  the  disc  becomes  dead-white  in  colour  but  with  an  irregular, 
smeary  edge  differing  from  the  cases  of  primary  atrophy  (i.e.  not  preceded 
by  neuritis),  in  which  the  discs  are  small,  well  and  sharply  outlined,  and  of 
greyish-white  colour,  the  form  found  in  tabes  being  a  good  example  of  this 
condition. 

The  effect  on  vision  will  be  of  the  eye  affected,  but  may  vary  in  different 
parts  of  the  field  ;  thus  in  poisoning  with  tobacco  there  is  a  central  scotoma 
(patch  of  lost  vision)  for  red  and  green,  and  this,  with  the  pallor  of  the 
temporal  side  of  the  disc,  implies  some  atrophy  of  the  fibres  supplying  the 
yellow  spot. 

It  is  important  to  recognize  that  severe  neuritis  may  be  associated  with 
but  little  defect  of  vision  for  some  time,  and  hence  not  to  assume  that 
the  fundi  are  normal  because  a  patient  sees  well. 

Affection  of  the  optic  chiasma  usually  affects  the  inner  or  nasal  fibres, 
leading  to  blindness  on  the  inner  (nasal)  sides  of  the  retinae  or,  as  referred 
to  visual  fields,  "  temporal  blindness."  When  one  optic  "  tract  "  is  affected 
the  temporal  half  of  the  retina  on  the  same  side  and  the  nasal  half  on  the 
other  will  become  blind,  so  that  there  is  loss  of  the  half -field  of  vision  of  the 
opposite  side,  e.g.  if  the  right  optic  tract  is  destroyed  the  patient  cannot 


670  A  TEXTBOOK  OF  SURGERY 

see  objects  in  the  Left  side  of  his  visual  field  ;  the  loss  is  the  same  if  the 
lesion  is  in  the  cortical  centre  of  the  occipital  lobe  on  that  side.  The  different 
situation  is  shown  by  Wernicke's  pupil  reaction,  which  consists  in  dissecting 
a  beam  of  light  into  the  blind  half  of  the  eye  ;  if  the  pupil  reacts,  the  lesion 
is  above  the  optic  tract,  possibly  in  the  occipital  cortex,  but  if  the  pupils 
remain  stationary  it  proves  that  the  optic  tract  is  affected  and  the  pupillary 
reflex  centres  in  the  basal  ganglia  thus  cut  out. 

(3)  The  Oculomotor  Nerves  (Third,  Fourth,  and  Sixth),  (a)  The  third 
(oculo-motor)  nerve  may  be  affected  in  injuries,  gummata,  tumours,  or 
aneurysms  of  the  orbit,  sphenoidal  fissure,  or  base  of  the  skull,  and  is  seldom 
entirely  affected  except  in  central  lesions  of  the  floor  of  the  third  ventricle, 
and  then  the  resulting  paralysis  is  associated  with  that  of  the  fourth  and 
sixth  nerves,  being  known  as  "  ophthalmoplegia  externa,"  in  which  case 
the  eyeball  is  immobile,  there  is  ptosis,  and  the  pupil  may  be  dilated  ;  such 
cases  are  often  syphilitic,  and  react  to  antisyphilitic  treatment.  Ophthalmo- 
plegia with  venous  congestion  of  the  eyeball  is  caused  by  thrombosis  of 
the  cavernous  sinus  or    aneurysmal  varix. 

Where  the  whole  third  nerve  alone  is  paralysed  there  is  ptosis,  dilatation 
of  the  pupil,  loss  of  accommodation,  slight  exophthalmos,  loss  of  pupillary 
reaction  to  light ;  external  strasbismus  is  present,  the  eye  not  moving 
upward,  downward,  or  inward  ;  partial  paralysis  is  a  more  usual  condition, 
ptosis  and  dilatation  of  the  pupils  being  alone  found. 

(b)  Paralysis  of  the  fourth  nerve  alone  is  not  common  nor  easy  to  detect, 
but  owing  to  impaired  movement  of  the  eye  in  the  downward  direction  there 
is  diplopia  on  looking  down,  and  for  this  reason  difficulty  in  going  downstairs. 

(c)  The  sixth  (abducent)  nerve  may  be  paralysed  from  fractures  of  the 
base,  from  gummas,  aneurysms  or  tumours,  and  the  results  are  internal 
strabismus  and  diplopia  on  attempting  to  look  to  the  affected  side. 

In  both  external  and  internal  strabismus  of  paralytic  origin  the  patient 
holds  the  head  sideways  (turned  in  the  opposite  direction  to  the  deviation 
of  the  eye)  in  order  to  make  the  optic  axes  parallel  and  so  obtain  binocular 
vision. 

(4)  The  Fifth  (Trigeminal  or  Trifacial)  Nerve.  This  nerve  may  be 
affected  with  sensory  or  motor  paralysis  or  spasm  as  a  whole  or  of  its 
branches,  but  the  most  important  condition  occurring  here  is  that  of 
trigeminal  neuralgia. 

(a)  Motor  Affections.  Division  of  the  whole  nerve  or  its  motor-root  may 
occur  in  fracture  of  the  upper  jaw  or  the  base  of  the  skull  or  inflammations 
around  the  nerve,  and  will  cause  paralysis  of  the  masseter,  temporal  and 
pterygoid  muscles  on  that  side,  but  little  inconvenience  results,  since  the 
muscles  on  the  sound  side  serve  well  for  mastication.  The  jaw  is  deflected 
towards  the  paralysed  side  by  the  unopposed  external  pterygoid  ;  the 
palate  is  not  paralysed. 

Spasm  of  the  masticatory  muscles  or  trismus  is  found  in  tetanus,  occa- 
sionally in  hysteria,  and  most  often  from  reflex  irritation,  as  that  due  to  an 
impacted  wisdom-tooth  or  caries  of  the  jaw. 


TRIGEMINAL  NEURALGIA  671 

(b)  Sensory  changes  may  be  produced  by  pressure  from  injury,  inflam- 
mation, tumour,  &c.,  and  in  such  cases,  in  addition  to  pain,  there  is  always 
loss  of  sensation  in  the  area  supplied,  as  found  in  other  nerves  (not  in  neu- 
ralgia), first  of  epicritic  and  then  of  protopathic  sensation.  In  cases  where 
the  Gasserian  ganglion  has  been  removed  there  is  loss  of  all  forms  of  sensa- 
tion, epicritic,  protopathic  and  deep,  over  an  area  of  the  face,  forehead, 
and  scalp  represented  by  tying  a  string  round  between  the  mid  inio-nasal 
point  and  just  behind  the  tip  of  the  chin.  Epicritic  sensation  is  also  lost 
over  a  slightly  larger  area  extending  back  in  the  region  of  the  orbit  to  the 
ear,  including  the  anterior  part  of  the  meatus.  There  is  but  little  over- 
lapping of  this  area  by  the  nerves  of  the  cervical  plexus.  The  mucosa  of  the 
mouth  is  insensitive  to  epicritic  and  protopathic  stimuli  from  the  circum- 
vallate  papillae  forwards,  including  the  cheeks  and  gums  from  the  anterior 
pillar  of  the  fauces  ;  the  nasal  mucosa  is  also  affected.  Taste  is  not  perma- 
nently destroyed.  Anaesthesia  of  the  cornea  is  occasionally  followed  by 
ulceration  and  ultimate  loss  of  the  eye.  The  main  divisions  of  the  nerve 
may  be  injured  separately  ;  if  the  ophthalmic  division  be  affected,  as 
from  fracture  of  the  anterior  fossa,  frontal  sinus  disease,  &c,  there  will 
result  anaesthesia  of  the  eyelids,  forehead,  and  scalp  as  far  back  as  the  mid 
inio-nasal  point  :  injury  of  the  other  divisions  causes  little  sensory  loss. 

(c)  Trifacial  Neuralgia  (tic  douloureux).  The  previously  described 
affections  of  the  fifth  nerve  are  of  little  but  diagnostic  interest ;  the  matter 
is  otherwise  with  trifacial  or,  as  it  is  sometimes  named,  epileptiform  neuralgia 
and  neuralgia  quinti  major.  This  is  one  of  the  most  distressing  diseases 
known  and  is  of  absolutely  unknown  pathology,  no  abnormality  having  yet 
been  detected  in  the  nerve  or  ganglion.  Cases  of  pain  in  the  nerve  from 
pressure  of  tumours,  &c,  are  associated  with  anaesthesia  and  of  cmite  different 
nature.  One  can  only  suppose  that  the  underlying  fault  is  in  the  Gasserian 
ganglion,  since  its  removal  is  the  only  certain  means  of  cure  for  this  terrible 
disease. 

Signs.  The  disease  commences  in  middle  life,  for  no  obvious  reason,  in 
some  branch  of  the  maxillary  or  mandibular  divisions  of  the  fifth  nerve, 
never  in  the  ophthalmic.  The  attacks  of  pain  are  at  first  of  short  duration 
and  with  long  intervals  between,  starting  at  some  point  and  radiating  along 
the  nerve  supplying  this.  As  the  disease  progresses  the  intervals  become 
shorter  and  the  attacks  of  pain  more  severe  and  enduring,  radiating  to 
further  branches  of  the  nerve,  and  by  their  severity,  as  well  as  their  sudden 
onset,  well  deserving  the  title  epileptiform.  The  attacks  are  brought  on 
by  touching  the  skin,  as  in  shaving,  brushing  the  hair,  cleaning  the  teeth, 
and  even  on  masticating  or  talking,  till  the  patient  is  in  a  pitiable  condition, 
worn  out  by  incessant  pain  and  worry,  and  becomes  a  drug-fiend  or  suicidal. 
In  addition  to  the  pain  there  may  be  spasm  of  facial  muscles  on  the  affected 
side,  the  hair  becomes  grey  and  falls  out,  while  local  hyperaemia,  salivation, 
and  lacrymafion  are  noted. 

Diagnosis.  A  consideration  of  the  various  causes  of  pain  in  the  head 
and   face  will    help  the   surgeon   to   exclude  cases   other  than   those   of 


A  TEXTBOOK  OF  SURGERY 

true   epileptiform  tic.      The  following  points  (Hutchinson)  will  be  very 
helpful  : 

(/;)  Pain  due  to  infections  or  blood-states  (toxaemias)  such  as  gout, 
malaria,  anaemia,  renal  disease,  requiring  appropriate  and  specific  treatment 
in  each  instance. 

(b)  Neuritis  such  as  the  initial  stage  of  herpes  zoster  ophthalmicus 
occurring  in  the  ophthalmic  division  (where  true  tic  is  unknown),  neuritis 
from  tumour,  will  be  characterized  by  the  persistent  and  not  spasmodic 
nature  of  the  pain,  and  there  will  also  be  affection  of  motion  and  sensation 
in  the  latter  condition. 

The  lightning-pains  of  tabes  may  occur  in  the  fifth  nerve,  and  hence  this 
disease  must  be  excluded. 

(c)  Local  Causes.  (1)  In  the  skull  as  syphilitic  nodes  or  headache  of 
secondary  syphilis ;  the  serum  reaction  and  other  signs  will  indicate  the 
line  of  treatment. 

(2)  The  eye  when  the  headache  is  frontal  from  eye-strain,  temporal  from 
glaucoma  and  iritis. 

(3)  The  nose  and  accessory  sinuses  when  inflamed  or  suppurating, 
enlarged  turbinates,  deviation  of  the  septum,  ethmoidal  disease. 

(■A)  The  teeth,  as  carious  stumps,  impacted  wisdom-teeth. 

The  disease  may  be  imitated  by  hysteria,  but  the  pain  is  not  so  severe 
and  does  not  constantly  increase  in  severity. 

The  following  salient  features  of  the  disease  will  serve  to  complete  its 
identification. 

(1)  The  pain  is  unilateral ; 

(2)  and  commences  in  the  maxillary  or  mandibular  divisions  of  the 
nerve,  never  in  the  ophthalmic,  which  is  seldom  involved  even  later. 

(3)  The  pain  is  paroxysmal  with  intervals  of  freedom,  and  increases  in 
severity  which  points,  in  addition  to  the  absence  of  anaesthesia,  distinguish 
from  neuritis. 

(4)  The  usual  age  is  thirty  to  fifty. 

(5)  There  may  be  facial  spasm  during  the  attack. 

(6)  The  attacks  are  brought  on  by  cold  pressure,  movements,  &c. 

(7)  The  intervals  are  painless. 

(8)  Medical  measures  afford  no  more  than  temporary  relief,  but  excision 
of  the  Gasserian  ganglion  cures  completely. 

Treatment.  Drugs  may  be  dismissed  as  useless  where  the  condition  is 
truly  that  of  trigeminal  neuralgia,  morphia  being  the  only  one  that  will 
give  relief,  at  the  expense  of  establishing  the  morphia-habit. 

Operative  measures  fall  into  three  groups  :  (1)  Injecting  alcohol  into 
the  ganglia  of  the  nerve.  (2)  Removing  peripheral  portions  of  the  nerve 
and  ganglia.     (3)  Removing  more  or  less  of  the  Gasserian  ganglion. 

(1)  Injection  of  alcohol  is  done  by  passing  a  hollow  needle  deep  into 
the  cheek  below  the  zygoma  so  that  its  end  travels  into  the  spheno-maxillary 

a  to  reach  Meckel's  ganglion  or  into  the  foramen  ovale  to  reach  the 
third  division,  when  a  small  amount  of  alcohol  is  injected  and  causes  destine- 


TREATMENT  OF  TRIGEMINAL  NEURALGIA  673 

tion  of  the  surrounding  nerve  structures.  There  may  be  difficulty  in  hitting 
off  the  required  spot,  and  the  patient  must  not  be  deeply  anaesthetized,  so  that 
the  extra  pain  when  the  nerve  is  reached  is  shown  by  a  facial  contortion.  Good 
results  are  reported,  lasting  some  months  at  least,  but  recurrence  is  common. 
(2)  Removal  of  peripheral  portions  of  the  nerve  (merely  dividing  or 
stretching  the  nerve  may  be  dismissed  as  quite  inadequate). 

Peripheral  operations  give  temporary  relief  and  are  less  dangerous  than 
the  large  operation  of  removing  part  of  the  Gasserian  ganglion  by  the  intra- 
cranial route.  A  few  of  these  may  be  considered  legitimate  in  the  early 
stages,  as  in  some  instances  the  pain  may  be  due  to  some  truly  local  condi- 
tion such  as  periostitis  of  the  inferior  dental  canal,  and  be  therefore  curable 
by  such  a  peripheral  operation.  The  following  indications  for  various 
forms  of  operation  given  by  Hutchinson  are  valuable  : 

The  only  peripheral  operations  worth  attempting  are  on  the  inferior 
dental  and  infra-orbital  nerves  when  these  alone  are  affected  ;  if  the  palatine 
nerves  are  affected  with  the  infra-orbital,  the  second  division  (maxillary) 
of  the  trigeminal  nerve  should  be  removed  by  the  intracranial  method 
with  the  corresponding  part  of  the  Gasserian  ganglion  ;  or  if  more  than 
one  branch  of  the  mandibular  (third)  division  be  affected,  this  should  be 
removed  by  intracranial  operation  with  part  of  the  ganglion.  In  all  cases 
where  branches  of  both  the  maxillary  and  mandibular  divisions  are  affected, 
these  should  be  removed  inside  the  cranium  with  the  outer  part  of  the 
Gasserian  ganglion  corresponding  to  them. 

(a)  The  supra-orbital  nerve  is  unlikely  to  require  surgical  treatment,  but 
may  be  exposed,  if  necessary,  by  an  incision  along  the  lower  margin  of  the 
eyebrow,  picked  up  in  its  notch  or  foramen  and  traced  back  along  the  orbital 
roof  till  the  supratrochlear  branch  is  found,  when  it  may  be  twisted  out. 

(6)  The  Infra-orbital  Nerve  and  Maxillary  Division.  As  has  been 
mentioned,  if  the  palatines  are  affected  as  well,  the  division  should  be  reached 
through  the  skull,  but  if  the  infra-orbital  alone  be  affected  it  may  be  removed 
with  Meckel's  ganglion  through  the  antrum  (the  Braun-Lossen  method,  by 
reflecting  the  zygoma  and  coronoid  to  reach  the  sphenomaxillary  fossa,  is 
inconvenient  from  haemorrhage  and  likely  to  lead  to  much  stiffness  of  the 
jaw).  The  antral  route  of  Carnochan  modified  by  Storrs  consists  in  horizontal 
incision  just  belowT  the  orbit  with  a  vertical  cut  down  from  the  centre  of 
this  ;  the  flaps  are  dissected  up  and  the  infra-orbital  nerve  identified.  The 
front  of  the  antrum  around  this  is  cut  away  freely  and  the  nerve  traced 
back,  raising  the  periosteum  from  the  orbital  floor  as  one  passes  back  ;  the 
posterior  outer  wall  of  the  antrum  is  cut  away  to  a  similar  extent,  thus 
opening  the  spheno-maxillary  fossa,  and  the  nerve  with  Meckel's  ganglion 
removed  with  a  snare.     (Fig.  252,  d,  e.) 

Kocher,  to  perform  this  operation,  approaches  the  pterygo-maxillary 
fossa  by  reflecting  the  malar-bone  outwards  and  thus  opening  the  outer 
part  of  the  antrum  of  Highmore.     (Fig.  252,  b,  r,  c',  c".) 

(c)  The  Inferior  Maxillary  (Mandibular)  Division.    The  only  branches 
worth  attacking  alone  are  the  inferior  dental  and  occasionally  the  lingual, 
i  43 


674 


\  TKXTHOOK  OK  SI  IJ(,Ki;v 


(1)  The  inferior  dental  Bhould  be  attacked  before  it  reaches  the  interior 
dental  canal  as  follows  :  A  flap  of  skin  and  niasseter  is  raised  forwards  from 
the  angle  of  the  jaw,  taking  care  not  to  carry  the  vertical  incision  more  than 
an  inch  and  a  half  above  the  angle,  or  the  facial  nerve  may  be  divided.  The 
jaw  is  pierced  with  a  three-quarter-inch  trephine  just  where  a  vertical  line 
carried  up  from  the  angle  meets  the  continuation  backward  of  the  alveolar 
margin  ;  the  opening  is  enlarged  with  rongeur-forceps  and  the  inferior  dental 
nerve  identified  and  twisted  out   (some  surgeons  reflect  a  large  flap  and 


In..  LVc'.     Operation  on  branches  of  the  trigeminal  nerve,     a.  Incision  to  expose 

tin-  supraorbital  nerve,     b,  Skin  incision,  r,  c',  c',  Bone  section  to  expose  Meckel's 

ganglion  by  Kocher's  method.     '/.  Skin  incision,     e,  Bone  section  to  reach  Meckel's 

ganglion  via  the  antrum  of  Highmore.     (Carnochan.) 


enlarge  the  sigmoid  notch  of  the  jaw  downwards)  ;   through  either  of  these 
openings;  the  lingual  nerve  may  be  found  and  divided.     (Fig.  253.) 

(2)  The  lingual  nerve  has  also  been  divided  inside  the  mouth  for  neuralgia 
but  with  little  success,  though  for  the  pain  of  inoperable  epithelioma  of  the 
tongue  the  result  may  be  good.  The  nerve  is  found  where  it  crosses  the 
floor  of  the  mouth  from  t  he  side  to  the  tongue,  opposite  the  last  lower  molar 
tooth.  The  tongue  is  pulled  to  the  opposite  side  of  the  mouth,  the  mucosa 
incised  at  the  point  mentioned,  and  the  nerve  found  just  beneath  the  latter  ; 
a  good  inch  should  be  removed. 


EXOISTOX  OF  THE  GASSERIAN  GANGLION 


675 


Where  the  above  operations  fail  or  recurrence  takes  place,  as  is  not 
improbable,  or  where  two  divisions  or  two  large  branches  of  one  division 
are  involved,  the  origin  of  the  nerve  inside  the  skull  must  be  exposed,  since 
the  pterygoid  route  of  Rose  is  no  longer  regarded  as  safe  or  satisfactory 
owing  to  the  limited  view  obtained,  the  depth  of  the  operation,  the  haemor- 
rhage, and  the  risk  of  injuring  the  Eustachian  tube  and  dura  or  causing 
fixity  of  the  jaw. 

(d)  Intracranial  Operations  on  the  Gasscrian  Ganglion.  The  usual  proce- 
dure is  that  by  the  Hartley-Krause  method  ;  occasionally  Cushing's  modifi- 
cation may  be  advisable.     As  in  all  probability  the  ophthalmic  division 


DURA 


mm 


Fig.  253.     Method  of  approaching  the  Gasserian  ganglion  through  (lie  skull;    the 

ganglion  and  its  three  branches  are  seen  ;  the  dotted  line  shows  the  line  of  section. 

mm,  The  middle  meningeal  artery  tied.     On  the  lower  jaw  is  indicated  the  spot  to 

trephine  to  find  the  inferior  dental  nerve. 


will  not  be  interfered  with,  there  will  be  no  need  to  suture  the  lids  together 
in  order  to  protect  the  eye:  the  conjunctiva]  sac  should  be  cleansed  by 
irrigation  with  1  in  10,000  biniodide  of  mercury  solution,  and  if  any  focus 
connected  with  the  eye  be  present,  suppuration  in  the  lachrymal  sac,  this 
should  be  removed  before  the  major  operation  is  undertaken  ;  a  healthy  eye 
is  unlikely  to  suffer  even  when  the  ophthalmic  division  is  removed. 

The  patient  is  under  combined  morphia-chloroform  narcosis  and  half- 
sitting  in  a  dental  chair  to  diminish  venous  oozing,  which  is  one  of  the 
difficulties  to  be  met  with.  The  half-scalp  is  shaved  and  rendered  sterile, 
as  well  as  the  external  auditory  meatus  and  ear.  A  flap  is  turned  down, 
consisting  of  scalp  and   temporal   muscle,  having  its  base  at  the  zygoma 


\    rEXTBOOK  OF  SURGERT 

and  extending  t ^ «>  inches  above  this  line  :  bhe  skull  is  opened  with  trephine 
and  rongeur-forceps  ;  t  here  la  no  advantage  in  making  an  osteoplasl  ic  flap. 

The  bone  removed  is  mostly  the  squamous  part  of  the  temporal  and 
part  of  the  great  wing  of  the  sphenoid.     In  trephining  it  is  well  to  remember 

that  the  bone  may  be  very  thin  at  this  part  and  the  underlying  dura  and 
vessels  easily  damaged.  The  bone  is  thoroughly  removed  till  the  base  of 
the  skull  is  reached.  Next  the  dura  is  stripped  inwards  from  the  base  of 
tin-  skull.  The  foramen  ovale  is  about  an  inch  and  a  half  inwards  from 
t  li<v  Bide  wall  of  the  skull  and  level  with  the  eminentia  artieularis  of  the  zygoma 
in  a  coronal  plane  ;  the  foramen  spinosum  is  slightly  behind  and  not  quite 
>o  tar  inward  as  the  foramen  ovale,  while  the  foramen  rotundum  is  rather 
deeper  inward  and  half  an  inch  in  front  of  the  foramen  ovale.  (Fig.  253.) 
Tims  t  In'  middle  meningeal  artery  coming  through  the  foramen  spinosum  will 
be  exposed  first  and  should  be  divided  between  two  ligatures,  as  this  will  pre- 
vent much  troublesome  bleeding,  which  is  important  in  an  operation  where 
constant  and  patient  swabbing  with  small  sponges  is  very  necessary.  The 
temporo-sphenoidal  lobe  in  its  dural  covering  is  raised  from  the  floor  of  the 
middle  fossa  with  a  broad  retractor,  and  the  second  and  third  divisions 
identified  as  they  pass  through  their  respective  foramina  and  traced  back 
to  the  Gasserian  ganglion,  raising  the  dura  to  expose  this.  When  the  dura 
is  thus  raised  and  the  lower  divisions  and  the  ganglion  well  exposed,  it 
must  be  decided  what  to  do.  Where  the  neuralgia  is  entirely  of  the  second 
(maxillary)  division,  Hutchinson  advises  removal  of  the  intracranial  part 
of  this  division  between  the  foramen  and  the  ganglion,  but  that  where  the 
second  and  third  divisions  are  involved  these  should  be  divided  at  their 
foramina  with  a  curved  tenotome  and  removed  with  the  outer  two-thirds  of 
the  ganglion.  In  any  case  the  ganglion  should  be  exposed  till  the  main 
t  nominal  trunk  comes  into  view,  the  ganglion  appearing  as  a  reddish- 
grey  meshwork  of  fibres  and  the  trunk  being  solid  and  white.  Krause 
clears  the  ganglion  to  its  inner  border  at  the  cavernous  sinus  but  no  further, 
and  leaves  the  ophthalmic  division  alone  owing  to  the  danger  of  injuring 
the  sinus  or  the  oculo-motor  nerves  which  lie  in  its  walls.  He  then  removes 
all  the  ganglion  and  the  second  and  third  divisions  to  their  foramina,  but 
leaves  the  ophthalmic  division. 

In  most  instances  it  will  suffice  to  remove  the  outer  two-thirds  of  the 
ganglion,  since  the  ophthalmic  is  practically  never  affected  and  in  the 
further  dissection  inwards  there  is  danger  to  the  sinus  and  oculo-motor 
nerves.  It  may  be  objected  that  partial  removal  may  be  followed  by 
recurrence,  but  Hutchinson,  who  removes  the  outer  third  only,  has  had 
such  freedom  from  recurrence  that  this  danger  may  be  disregarded,  and  the 
less  severe  operation  will  certainly  be  shorter  and  safer.  Bleeding  can 
usually  be  checked  by  temporary  pressure  :  packing  with  gauze  is  to  be 
avoided,  the  depths  of  the  wound  being  drained  with  a  small  tube  for 
twenty-four  hours.  There  is  no  need  to  replace  any  bone  in  the  gap.  Where 
the  whole  ganglion  has  been  removed  the  cornea  needs  care,  a  Buller's  shield 
being  worn  at  first. 


THE  FACIAL  NERVE  077 

• 

In  Cushing's  method  the  flap  does  not  extend  so  high  on  the  skull  but 
its  base  is  lower  and  the  zygoma  divided  at  the  ends  and  reflected  with  the 
flap  ;  part  of  the  base  of  the  skull  is  removed  as  well  as  the  inside-wall, 
and  the  whole  ganglion  removed  with  all  the  divisions  of  the  nerve,  dissecting 
the  first  from  the  wall  of  the  cavernous  sinus.  This  more  severe  operation 
will  but  seldom  be  necessary.  Preservation  of  the  motor-root  is  not  possible 
except  by  chance.  The  mortality  varies  from  4  to  20  per  cent.,  the  former 
in  the  hands  of  those  who  have  much  practice;  and  once  removed,  the 
neuralgia  never  returns. 

(5)  The  Seventh  (Facial)  Nerve.  This  nerve  is  entirely  motor  in  its 
extracranial  portion,  and  lesions  of  this  part  may  cause  paralysis,  but 
when  the  intracranial  portion  is  affected  taste  may  be  affected  on  the  side 
of  the  lesion,  while  spasm  as  well  as  paralysis  may  result. 

(a)  Spxsm  of  a  "  clonic  "  nature  may  be  due  to  lesions  of  the  cortical 
area,  the  pontine  nucleus,  or  the  intracranial  part  of  the  nerve,  and  must 
be  distinguished  from  "  habit  spasm  "  where  there  is  no  definite  lesion  : 
clonic  spasm  may  also  be  associated  with  trigeminal  neuralgia. 

Tonic  spasm,  or  rather  contracture,  may  follow  some  time  after  paralysis. 

Treatment.  Counter-irritants  over  the  point  of  exit  of  the  nerve,  such 
as  blistering  or  freezing,  nerve-stretching,  may  afford  temporary  benefit,  but 
usually  the  spasm  returns  as  the  nerve  recovers.  In  severe  cases  the  nerve 
may  be  divided  or,  better,  anastomosed  with  the  hypoglossal  or  spinal 
accessory  nerves. 

(b)  Paralysis  may  follow  lesions  of  the  upper  or  lower  segments  of  this 
nerve,  whether  injury,  haemorrhage,  inflammation,  or  tumour-formation. 

(1)  Upper-segment  or  supranuclear  lesions  of  the  seventh  nerve  cause 
paralysis  of  the  lower  part  of  the  face  only,  the  palpebral  movements  being 
unaffected  ;  there  is  no  reaction  of  degeneration.  The  paralysis  may  occur 
alone  but  is  more  often  part  of  a  hemiplegia,  and  is,  of  course,  on  the  opposite 
side  to  the  cerebral  lesion,  whether  this  is  in  the  cortex,  corona  radiata  or 
internal  capsule. 

(2)  Lower-segment  lesions  result  from  affections  of  the  pontine  nucleus 
or  any  part  below  this,  and  are  characterized  by  paralysis  of  the  whole  of 
the  facial  muscles  on  the  affected  side,  including  the  palpebrals,  while  the 
reaction  of  degeneration  will  be  found  in  the  more  severe  examples.  Differ- 
ences  according  to  the  connections  and  branches  of  the  nerve  point  out  the 
position  of  the  lesion. 

(a)  Nuclear  lesions  are  usually  associated  with  paralysis  of  the  opposite 
side  of  the  body  (crossed  paralysis)  from  affection  of  the  pyramidal  tract 
above  its  decussation.    The  nerve  itself  may  be  affected  : 

(l>)  In  the  skull,  as  in  fractures  of  the  base  of  the  skull,  when  the  auditory 
nerve  will  often  be  affected  as  well,  causing  an  internal-ear  deafness,  and 
if  above  the  chorda-tympani  branch,  loss  of  taste  in  the  same  side  of  the 
tongue.  In  the  aqueduct  of  Fallopius  the  nerve  is  often  affected  in  middle- 
ear  disease. 

(<■)  Outside  the  skull  the  nerve  may  be  a  fleeted  by  cold,  which  is  the 


78  \  TEXTBOOK  OF  SURGERY 

cause  generally  assigned  for  mosl  cases  <>f  Bell's  palsy,  or  by  Injuries  such 
aa  operations  on  the  mastoid.  Eorcepa  in  delivery,  while  syphilitic  neuritis 
accounts  for  some  instances. 

s  jns.  In  the  lower-segmenl  form  the  whole  side  of  the  face  is  paralysed, 
appearing  unnaturally  smooth  and  expressionless;  the  palpebral  fissure 
is  wider  than  normal,  and  from  want  of  apposition  of  the  puneta  lacrvinalia 
and  action  of  the  small  tensor-tarsi  muscle,  epiphora,  or  watering  of  the 
eve.  will  he  found.  The  conjunctival  reflex  is  lost,  and  on  attempting  to 
close  the  eye  the  latter  rotates  upwards  ;  corneal  ulcers  from  failure  of  the 
lids  to  close  may  result.  The  difference  between  the  two  sides  of  the  face 
is  most  noted  when  the  patient  laughs  or  cries,  the  moving,  furrowed  side 
forming  a  marked  contrast  to  the  mask-like,  paralytic  side.  The  patient 
cannot  whistle,  and  on  attempting  to  show  the  teeth  the  lip  on  that  side 
remains  unietracted.  and  on  raising  the  forehead  the  paralysed  side  remains 
flaccid.  When  the  tongue  is  protruded  it  appears  to  deviate  to  the  affected 
side,  hut  its  relation  to  the  ineisor-teeth  is  symmetrical.  Food  collects 
between  the  paralysed  buccinator  and  the  teeth.  The  palate  is  not  affected. 
Loss  of  taste  may  occur  on  the  affected  side. 

In  the  upper-segment  type  the  escape  of  the  upper  part  of  the  face 
and  the  fact  that  voluntary  rather  than  emotional  actions  are  affected,  as 
well  as  the  presence  of  other  upper-segment  palsy,  will  help  ;  the  electrical 
i -act  ions  may  be  of  assistance,  but  as  the  reaction  of  degeneration  may  not 
be  present  in  minor  degrees  of  lower-segment  lesions  its  absence  is  no  proof 
of  an  upper-segment  lesion.  Later,  contractures  of  the  paralysed  muscle 
may  follow,  causing  the  creases  on  that  side  to  be  deeper  than  normal  and 
causing  the  side  of  paralysis  to  be  mistaken  till  the  patient  smiles  or  closes 
the  eyes,  when  the  more  wrinkled  side  will  be  found  to  be  the  one  paralysed. 

Prognosis.  This  is  good  in  the  idiopathic  (rheumatic)  or  type  due  to 
cold,  but  the  electrical  reaction  also  gives  some  clues.  Where  the  muscles 
react  to  faradic  and  galvanic  current  recovery  is  probable  in  two  to  three 
weeks.  Should  the  faradic  and  galvanic  excitability  be  diminished  recovery 
may  take  eight  to  ten  weeks,  but  when  the  reaction  of  degeneration  is  present 
prognosis  is  poor  and  recovery  will  take  at  least  fifteen  months,  and  paralysis 
may  be  permanent.  Facial  paralysis  following  mastoid  operations  usually 
recovers  without  operation,  as  does  that  due  to  fractures  of  the  skull  and 
injury  to  the  lower  facial  twigs  in  submaxillary  operations. 

Treatment.  Daily  massage  and  electrical  treatment  to  improve  the 
nutrition  of  the  muscles  is  necessary  whether  operation  is  contemplated  or 
not.  as  well  as  alter  its  performance.  Where  due  to  mastoid  disease  the 
mastoid  should  he  explored  ;  where  the  nerve  is  cut  at  operation  the  ends 
should  he  sutured  or,  failing  this,  anastomosis  with  the  hypoglossal  carried 
out.  Cases  <»l  idiopathic  (rheumatic)  and  other  forms  of  paralysis  not 
improving  after  six  months,  where  there  is  a  reaction  of  degeneration  in 
tie   muscles,  should  be  treated  by  nerve  anastomosis. 

'I  he  reinforcing  nerve  for  choice  should  be  the  hypoglossal,  for  not 
only  i>  the  conical  centre  of  the  latter  nearer  that  of  the  face,  and  movement 


FACIO-HYPOGLOSSAL  ANASTOMOSIS  679 

of  the  tongue  and  face  arc  normally  associated,  but  dissociated  voluntary 
movements  of  the  face  return  more  quickly  when  the  hypoglossal  is  anas- 
tomosed than  when  the  spinal  accessory  is  used,  and  it  is  less  embarrass- 
ing and  equivocal  for  the  patient  when  he  wishes  to  smile  to  move  his 
tongue,  even  if  he  thrust  it  in  his  cheek,  than  to  shrug  the  shoulder.  The 
spinal  accessory  is  slightly  easier  to  find,  but  neither  the  spinal  accessory 
nor  the  hypoglossal  needs  much  search,  the  whole  difficulty  of  the  operation 
consists  in  finding  the  atrophic  facial  nerve. 

Facio-hypoghssal  Anastomosis.     An  incision  is  made  along  the  sterno- 
mastoid  from  just  below  the  external  auditory  meatus  to  the  cornu  of  the 


Fig.  2.34.     The  relations  of  the  facial  (VII).  hypoglossal  (XII),  and  spinal  accessory 
(XI)  nerves  for  nerve  anastomosis. 

hyoid  bone  and  the  sternomastoid  and  the  posterior  belly  of  the  digastric 
pulled  backwards.  The  facial  nerve  leaves  the  skull  just  behind  the  styloid 
process  (which  is  a  useful  landmark)  and  enters  the  parotid  gland,  where  it- 
is  found,  by  dissecting  in  the  angle  between  the  gland  and  the  anterior  edge 
of  the  digastric,  high  up  near  the  base  of  the  skull.  When  found  the  facial 
nerve  is  dissected  up  to  the  stylomastoid  foramen  and  divided.  The  hypo- 
glossal nerve  is  next  found  crossing  the  external  carotid  hooking  round  the 
origin  of  occipital  artery  in  the  lower  part  of  the  dissection  :  this  is  not 
difficult.  A  flap  of  half  or  less  of  this  nerve  is  turned  up  and  joined  to 
the  cut   end  of  the  facial  nerve,  with  the  finest  catgut,  the  junction  being 


A  TEXTBOOK  OF  SURGERY 

surrounded  with  Cargile  membrane.  Care  is  taken  to  dissect  up  both 
nerves  so  that  there  is  no  tension  on  the  line  of  union.  .  Little  paralysis  of 
the  tongue  results,  voluntary  power  in  successful  operations  begins  to 
return  in  the  lower  facial  muscles  in  three  to  six  months,  and  voluntary  dis- 
sociated  movements  may  occur  within  a  year  of  operation,  but  emotional 
movements,  as  smiling,  will  take  far  longer.  If  all  the  hypoglossal  be 
used,  its  peripheral  end  should  be  anastomosed  to  part  of  the  spinal  accessory 
nerve. 

(6)  The  eighth  (auditory)  nerve  may  be  injured  in  fractures  of  the 
base  of  the  skull,  usually  associated  with  lesions  of  the  facial  nerve  and 
t  a  using  permanent  internal-ear  deafness.  Tinnitus  and  auditory  vertigo  are 
mentioned  in  the  section  on  Affections  of  the  Ear. 

(7)  Little  is  known  of  the  affections  of  the  glosso-pharyngeal  (ninth) 
nerve  ;  it  contains  taste-fibres  for  the  posterior  third  of  the  tongue  and 
motor-fibres  to  the  middle  constrictor  and  stylopharyngeus  muscles. 

(8)  The  Tenth  (Vagus)  Nerve.  This  nerve,  which  is  reinforced  by  the 
accessory  part  of  the  spinal  accessory,  supplies  sensory-  and  motor-fibres 
to  the  pharynx,  larynx,  oesophagus,  lungs  and  stomach,  as  well  as  sensory 
and  inhibitory  fibres  to  the  heart.  Division  of  one  vagus  below  the  superior 
laryngeal  branch  is  by  no  means  fatal  and  may  make  little  difference  to 
the  patient,  and  hence  this  part  of  the  nerve  may  be  sacrificed  in  urgent 
operation  in  the  neck,  as  for  malignant  glands  and  tumours.  Irritation  of 
the  nerve,  as  by  pulling  with  retractors,  ligatures,  &c,  may  cause  fatal 
inhibition  of  the  heart.  Injury  to  the  superior  laryngeal  nerve  or  the  main 
vagus  above  the  origin  of  the  latter  will  lead  to  inspiration-pneumonia  from 
the  insensitive  state  of  the  larynx  ;  this  may  also  occur  in  paralysis  of  the 
branches  to  the  larynx  in  bulbar  paralysis.  The  motor-supply  to  the  larynx, 
with  the  exception  of  the  cricothyroid  muscle  (which  is  supplied  by  the 
external  laryngeal  nerve),  is  through  the  recurrent  laryngeal  nerve,  and  if 
this  be  injured,  as  may  happen  in  operations  on  the  thyroid  gland,  the 
vocal  cord  on  the  affected  side  will  be  motionless  in  the  mid-position  (cada- 
veric position)  between  ab-  and  adduction.  Pressure  on  the  nerve  by 
aneurysms  and  tumours  in  the  thorax  may  lead  to  paralysis  of  the  adductors 
or  abductors  on  one  or  both  sides  ;  double-abductor  paralysis  is  most 
dangerous  and  may  lead  to  sudden  suffocation.  Should  the  recurrent 
laryngeal  nerve  be  injured  at  operation  the  ends  should  be  sutured  if  possible 
(which  is  unlikely) ;  however,  except  for  alteration  of  the  voice,  little  harm 
will  result. 

(9)  The  Spinal  Accessory  {Eleventh)  Nerve.  This  nerve,  after  giving  off 
the  accessory  fibres  to  the  vagus,  forms  the  motor-supply  to  the  sterno- 
inastoid  and  upper  part  of  the  trapezius.  Affections  of  this  nerve  may  cause 
spasm  or  paralysis. 

(a)  Spasm  may  be  tonic  and  acute,  due  to  irritation,  usually  of  inflamed 
glands  of  the  neck,  being  then  of  reflex  nature  and  disappearing  when  the 
cause  is  removed  or  mitigated. 

The    clonic  variety  is    chronic   and   due    to    affection   of  the  central 


THE  SPINAL  ACCESSORY  NERVE  081 

connexions  of  the  nerve.  The  signs  are  jerking  movements  of  the  sterno- 
mastoid  and  trapezius,  causing  a  variety  of  torticollis,  the  head  being  flexed 
to  the  affected,  the  face  rotated  to  the  other  side  (see  Torticollis,  p.  458), 
which  may  be  very  embarrassing  and  likely  to  spread  to  other  muscles. 
Hypertrophy  of  the  constantly  contracting  muscles  results. 

Treatment.  Sedatives  such  as  bromides  and  the  constant  current  should 
be  tried  ;  failing  this,  stretching  or  avulsion  of  the  nerve  may  be  practised, 
but  after  temporary  success  recurrence  is  frequent :  section  of  the  posterior 
cervical  roots  has  also  been  done  for  this  affection,  but  with  doubtful  benefit. 

Paralysis.  The  nerve  may  be  divided  in  either  the  anterior  or  posterior 
triangle  of  the  neck,  usually  in  operations  to  remove  enlarged  lymph-nodes. 
If  divided  in  the  anterior  triangle  both  the  sternomastoid  and  trapezius 
are  paralysed — in  the  latter  instance  only  the  upper  part  of  the  trapezius. 
Paralysis  of  the  sternomastoid  produces  little  disability  of  motion  ;  paralysis 
of  the  upper  trapezius  results  in  dropping  of  the  shoulder  and  weakness  of 
the  upper  limb  from  imperfect  fixation  of  the  scapula  ;  should  the  whole 
muscle  be  paralysed,  as  when  the  cervical  supply  in  addition  is  divided, 
the  arm  cannot  be  raised  above  the  head. 

Treatment.  Suture  of  the  nerve  should  be  done  as  soon  as  possible,  or, 
if  this  is  not  feasible,  reinforcement  from  the  lower  motor  branches  of  the 
cervical  plexus. 

(10)  The  Hypoglossal  (Twelfth)  Nerve.  This  may  be  affected  in  its 
upper  or  lower  segment,  and  being  the  special  motor-nerve  for  the  intrinsic 
muscles  of  the  tongue,  the  result  will  be  paralysis  of  one-half  of  the  tongue, 
which  when  protruded  deviates  to  the  paralysed  side.  In  lesions  of  the 
lower  segment  there  will  be  also  wasting  of  the  affected  side.  The  nerve 
may  be  involved  in  fractures  through  the  posterior  fossa  of  the  skull  in 
chronic  meningitis  and  tumours  or  divided  at  operations.  When  the  lesion 
is  above  the  medullary  nucleus  there  will  be  associated  hemiplegia  and  no 
wasting  of  the  muscles. 

The  effects  are  impairment  of  mastication,  swallowing  and  speech, 
which  are  of  a  transitory  nature. 

B.  Spinal  Nerves.  ( 1 )  The  Cervical  Plexus  and  Upper  Cervical  Nerves. 
Both  motor  and  sensory  affections  occur. 

(a)  Sensory  branches  are  often  divided  at  operation,  especially  in  the 
posterior  triangle,  and  seldom  cause  trouble  ;  where  large  branches  are 
divided  they  should  be  sutured  at  the  close  of  the  operation.  Should  the 
nerves  be  involved  in  a  scar  and  cause  irritative  symptoms  (causalgia)  they 
should  be  excised  with  the  scar. 

(b)  Cervico-occipital  neuralgia  occurs  in  the  distribution  of  the  great 
and  small  occipital  and  great  auricular  nerve.  In  severe  instances  it  may 
be  necessary  to  excise  portions  of  the  nerves  or  divide  their  posterior  roots 
inside  the  dura. 

(«)  The  phrenic  nerve  is  the  most  important  branch  of  the  cervical  plexus 
and  may  be  injured  in  operations  in  Eront  of  the  scalenus  anticus  :  inclusion 
in  a  ligature  has  led  to  persistent  hiccough  and  death  from  lung  complica- 


?2 


\  T KXTBOOK  OK  SURGERY 


tions,  Inn  as  a  rule  placing  <me  phrenic  hors  <l<  combat  does  not  cause  any 
great  trouble.  Where  both  nerves  are  paralysed,  as  in  diphtheria]  neuritis, 
the  abdomen  is  sucked  in  during  inspiration,  which  is  performed  by  the 
accessory  muscles  of  respiration.     Lesion  of  one  phrenic  may  produce  little 


Fig.  255.     Sympathetic  palsy  on  left  Bide  due  to  lympho- sarcoma  of   the   neck. 
Note  on  left  side  (1)  Recession    of   the  eyeball;     (2)  Narrow  palpebral  fissure; 

(3)  Small  pupil. 


effect,  but  on  radiographic  examination  the  diaphragm  will  be  seen  motion- 
less on  the  affected  side  and  considerably  higher  owing  to  its  relaxation.  If 
accidentally  divided  at  operation  the  nerve  should  be  sutured. 

(2)  The  Cervical  Sympathetic.  This  may  be  injured  in  the  neck  at 
operations,  or  its  white  rami  communicantes,  coming  from  the  first  and 
second  dorsal  nerves,  may  he  torn  in  injuries  to  the  brachial  plexus. 


THE  BRACHIAL  PLEXUS  683 

('/)  Paralysis  of  the  sympathetic  causes  slight  ptosis  from  paralysis  of 
the  involuntary  muscle  of  the  eyelid  and  slight  exophthalmos  ;  the  pupil  is 
smaller  than  normal  and  does  not  dilate  on  shading  the  eye  or  on  placing 
cocain  in  the  conjunctival  sac  or  pinching  the  skin  of  the  side  of  the  neck 
(cilio-spinal  reflex),  but  reacts  to  light  and  accommodation.  The  palpebral 
fissure  is  narrowed  and  the  affected  side  of  the  face  and  upper  limb  do  not 
flush  and  sweat  if  pilocarpin  be  given. 

Stimulation  of  the  sympathetic  is  less  usual,  resulting  in  dilatation  of 
the  pupil,  a  wide  palpebral  fissure,  exophthalmos,  and  unilateral  sweating 
and  flushing  of  face  and  arm.  When  paralysis  is  complete  recovery  is 
unlikely. 

Excision  of  the  cervical  sympathetic  for  epilepsy,  exophthalmic  goitre, 
and  glaucoma  is  based  on  erroneous  pathology,  and  is  no  longer  advised. 

(3)  The  Brachial  Plexus  and  its  Branches,  (a)  The  Plexus.  This 
plexus  consists  of  the  anterior  primary  divisions  of  the  lower  four  cervical 
nerves  and  of  the  first  dorsal  nerve.  The  distribution  of  the  motor-fibres 
of  the  plexus  is  clinically  as  follows  (Sherren)  : 

The  fifth  cervical  root  supplies  the  deltoid,  biceps,  brachialis  anticus, 
supinators,  spinati,  and  rhomboids. 

The  sixth  cervical  root  supplies  the  pronators  of  the  forearm,  the  radial 
extensors,  the  clavicular  part  of  the  pectoralis  major,  and  the  serratus 
magnus. 

The  seventh  cervical  root  supplies  the  triceps,  extensors  of  the  fingers, 
extensor  carpi  ulnaris,  and  pectoralis  major. 

The  eighth  cervical  root  supplies  the  flexors  of  the  wrist  and  fingers. 
The  first  dorsal  root  supplies  the  intrinsic  muscles  of  the  hand. 
Lesions  of  the  plexus  are  caused  in  two  ways  :  (-/)  Traction  injuries,  the 
shoulder  being  depressed  or  the  head  acutely  flexed  to  one  side,  producing 
overstretching  of  the  upper  components  of  the  plexus,  or  the  arm  being 
forcibly  abducted  from  the  side,  causing  traction  on  the  lower  components 
of  tin-  plexus,  (b)  Pressure  lesions,  ,-is  from  blows,  punctured  wounds,  and 
fractures  of  the  clavicle.  The  plexus  may  be  injured  in  its  upper  or  lower 
portion,  i.e.  in  the  supra-  or  infra-clavicular  part  of  its  extent. 

Supraclavicular  lesions  (trunk  or  division  lesions)  occur  at  birth  from 
Hexing  the  head  or  depressing  the  shoulder,  affecting  the  upper  part  of  the 
plexus  (fifth  cervical  root),  or  if  the  arms  are  carried  up  in  a  difficult  breech 
labour  the  lower  part  of  the  plexus  (eighth  cervical  and  first  dorsal  root) 
may  be  affected  :  paralyses  occurring  under  anaesthesia  (anaesthetic  palsy) 
form  another  importanl  group  of  the  same  nature,  either  pari  of  the  plexus 
being  overstretched.  The  nerve-sheaths  are  torn  ami  the  effused  blood 
compresses  the  nerve.  The  practical  conclusion  is  that  the  aims  should 
never  be  kept  long  in  the  fully  abducted  position  under  anaesthesia  or  the 
neck  severely  flexed  in  pulling  the  jaw  forward.  Cervical  ribs  are  another 
importanl  source  of  pressure  on  the  upper  plexus  ;  injuries  associated  with 
fractures  of  the  clavicle  and  penetrating  wounds  are  rare. 

The  upper  ami  lower  porl  ions  or  the  whole  plexus  may  be  affected. 


A  TEXTBOOK  OF  SURGERY 


[nfraclaviculai  lesions  (cord  lesions)  are  usually  due  to  compression 
in  dislocations  or  reduction  of  the  dislocated  humerus.     In  these  lesions 

the  whole  plexus  or  one  of  the  cords,  usually  the  inner,  may  be  affected. 

A.  Supraclavicular  Lesions,  (a)  The  whole  plexus,  which  is  not 
common, 

Signs.  There  is  loss  of  epicritic  and  protopathic  sensation  over  the 
forearm  and  hand  and  the  lower  third  and  outer  two-thirds  of  the  ami  ; 


FlG.  2.")(i.     To  show  the  loss  of  epicritic  and  protopathic  sensation  (shaded)  after 
total  division  oi  the  brachial  plexus.     (After  Sherren.) 

deep  touch  is  lost  over  the  forearm.  The  muscles  of  the  arm,  forearm,  and 
hand  are  in  a  state  of  flaccid  paralysis.  Involvement  of  the  sympathetic, 
spinati,  rhomboids,  pectorals,  and  serratus  depends  on  the  position  of  lesion  ; 
'he  rhomboids,  serratus,  and  sympathetic  commonly  escape. 

(b)  The  l'/>/»r-Arm  Type  of  Lesion  (Erb's  palsy).     The  fifth  and  sixth 

may  both  be  involved,  but  the  typical  defect  is  produced  when  the 

fifth  only  is  affected,  and  results  from  injuries  at  birth,  falls  on  the  point 


BRACHIAL  PLEXUS  LESIONS  685 

of  the  shoulder,  and  traction  under  anaesthesia.  There  is  no  loss  of  sensa- 
tion in  this  lesion.  Owing  to  the  paralysis  of  the  deltoid,  biceps,  brachialis 
anticus,  supinators  and  spinati,  the  arm  hangs  extended  by  the  side  inter- 
nally rotated  and  pronated,  the  back  of  the  hand  being  against  the  thigh. 
Flexion  of  the  forearm  may  be  recovered  by  adaptation  of  the  radial  extensors 
of  the  wrist.  Later,  subluxation  of  the  humerus  from  stretching  of  the 
deltoid  and  spinati  is  common. 

(c)  The  Lower-Arm  Type  (Klumpke).  This  results  from  over-abduction 
of  the  arm,  the  first  dorsal  root  being  chiefly  affected,  with  the  result  that 
the  intrinsic  muscles  of  the  hand  are  paralysed,  giving  the  "  complete  claw- 
! i in  id."  Affection  of  the  sympathetic  is  commonly  associated  with  this  lesion. 
There  is  anaesthesia  of  the  inner  side  of  the  arm,  forearm,  and  ulnar  border 
of  the  hand.  The  area  of  protopathic  is  greater  than  that  of  epicritic  loss, 
distinguishing  the  condition  from  injury  to  the  inner  cord  of  the  plexus 
lower  down.  Note  both  types  of  paralysis  may  be  produced  by  affections 
(poliomyelitis)  of  the  anterior  horn-cells  of  the  cord. 

B.  Infraclavicular  Lesions.  (1)  The  inner  cord  of  the  plexus  is  usually 
injured  by  dislocations  of  the  humerus,  the  results  being  paralysis  of  the 
intrinsic  muscles  of  the  hand  (claw-hand)  and  loss  of  sensation  over  the 
ulnar  border  of  the  forearm,  arm  and  hand,  which  is  usually  only  for  epicritic 
sensation,  the  division  of  the  cord  being  commonly  incomplete. 

(2)  Lesions  of  the  outer  cord  produce  paralysis  of  the  biceps,  coraco- 
brachialis,  and  all  the  muscles  supplied  by  the  median  except  the  intrinsic 
muscles  <>(  the  hand  (the  lesion  may  be  overlooked,  as  the  action  of  the 
muscles  is  partly  taken  on  by  others).  Sensation  is  impaired  on  the  radial 
border  of  the  forearm  and  hand. 

(.'})  Lesions  of  the  posterior  cord  cause  paralysis  of  the  muscles  supplied 
by  the  circumflex  and  musculo-spiral,  viz.  the  deltoid,  triceps,  supinator 
longus,  and  the  extensors  of  the  wrist  and  fingers. 

The  prognosis  of  the  above  lesions  depends  on  the  kind  of  injury  and 
the  position  in  the  plexus,  being  worse  the  higher  up  it  is  on  account  of  the 
greater  degeneration  of  muscles  below  before  their  innervation  is  renewed. 
Prognosis  is  best  in  the  minor  varieties  of  birth-palsies  and  traction-lesions, 
especially  when  of  the  incomplete  sort. 

Diagnosis  of  Brachial  Plexus  Lesions.  A  few  points  call  for  reitera- 
tion. The  grouping  of  paralysed  muscles  in  plexus  lesions  corresponds  to 
the  supply  of  no  single  nerve,  e.g.  Erb's  palsy  or  that  of  all  the  intrinsic 
muscles  of  the  hand.  Paralysis  of  the  serratus  magnus  and  rhomboids 
points  to  a  lesion  high  in  the  upper  part  of  the  plexus,  while  affection  of  the 
sympathetic  shows  that  the  lesion  is  high  in  the  lower  part  of  the  plexus. 
The  white  rami  of  the  fust  dorsal  to  the  sympathetic  are  given  off  just 
outside  the  intervertebral  foramen,  so  that  it  is  not  possible  to  get  above 
the  site  of  lesion  in  this  nerve  when  the  sympathetic  is  affected  (a  useful 
point  when  operative  measures  are  considered).  The  nerve  to  the  rhom- 
boids comes  off  the  fifth  and  that  to  the  serratus  magnus  from  the  fifth, 
sixth,  and  seventh  roots  close  to  the  intervertebral  foramen,  while  the  supra- 


\  TEXTBOOK  OF  SURGERY 

scapular  nerve  comes  from  the  union  of  the  fifth  and  sixth  roots  a  little 
further  out.  [ncomplete  division  <>f  the  fifth  mot  may  cause  paralysis  of 
the  spinati  and  deltoid  but  qo1  of  the  biceps  and  supinator,  which  may 
be  confused  with  injury  to  the  circumflex  aerve  unless  the  spinati  be 
examined  and  the  pa^tch  of  anaesthesia  over  the  deltoid  present  in  circumflex 
injuries  noted.  Sensation  is  lost  in  Lesions  <»t  the  whole  plexus  but  not  of 
isolated  anterior  divisions,  while  in  Lesions  of  tin-  spinal  cord  there  is  loss 
osation  of  heat,  cold,  and  pain  on  the  opposite  side  of  the  body,  which 
may  be  missed  unless  carefully  searched  for,  while  there  will  often  be  increased 
reflexes  below  the  lesion  and  upraising  plantar-reflex  (Babinski). 

Treatment.  As  most  of  the  lesions  are  subcutaneous,  an  accurate 
diagnosis  cannot  be  made  for  nearly  three  weeks,  when  if  the  reaction  of 
degeneration  be  present  exploration  should  be  made.  In  the  case  of  birth- 
palsies  of  infants  electrical  reactions  are  less  easy  to  ascertain,  and  one 
may  wait  three  months  before  exploring,  using  in  the  meantime  treatment 
to  prevent  contractures  and  maintain  the  nutrition  of  the  affected  muscles. 

Tin'  plexus  is  explored  through  an  incision  from  the  middle  of  the  pos- 
terior  border  of  the  sternomastoid  to  the  junction  of  the  middle  and  outer 
thirds  of  the  clavicle,  the  nerves  being  sought  as  they  emerge  between 
the  scalenus  anticus  and  medius.  This  will  suffice  for  the  upper  part  of 
the  plexus,  but  to  expose  its  lower  constituents  the  incision  must  be  carried 
further  down  and  the  clavicle  cut  through.  Early  operation  is  advisable, 
since  later  the  scar-tissue  around  renders  the  parts  of  the  plexus  much 
less  easy  of  identification.  The  phrenic  nerve  lying  on  the  scalenus  anticus 
must  be  respected.  The  lesions  are  treated  on  general  principles,  effusion 
being  let  out  of  sheaths  ;  where  there  is  division  of  a  cord  or  nerve  end-to- 
end  suture  should  be  done  if  possible,  or  if  the  upper  end  cannot  be  found 
the  lower  anastomosed  into  the  most  convenient  normal  division,  e.g.  the 
fifth  into  the  sixth  cervical  nerve  :    bulbous  scars  are  excised  and  anasto- 

is  carried  out.  Such  abnormalities  as  cervical  ribs  should,  of  course, 
be  removed.  The  after-treatment  is  very  important  whether  operation  be 
performed  or  not ;  the  paralysed  mus<  les  are  prevented  from  overstretching 
l>v  suitable  splinting,  and  massage  carried  out  daily.  In  the  case  of  the 
Erb  type  of  paralysis  the  arm  should  he  abducted  to  the  horizontal, 
the  forearm  flexed  to  a  right  angle,  supinated  and  so  splinted,  in  the 
Klumpke  type  it  will  he  difficult  to  prevent  the  development  of  ''claw- 
hand,"  but  attempts  should  he  made. 

(b)  Branches  of  the  Brachial  Plexus.  (I)  The  Long  Thoracic  Nerve 
ve  of  Bell).  This  comes  from  the  fourth,  fifth,  and  sixth  cervical  roots 
and  supplies  the  serratus  magnus.  This  nerve  is  most  usually  injured  by 
carrying  weights  on  the  shoulder, and  seldom  alone,  hut  together  with  the 
lower  part  of  the  trapezius  from  similar  affections  of  the  third  and  fourth 
cervical  roots.  The  result  is  marked  "  winging"  of  the  scapula,  the  Lower 
angle  being  very  prominent  and  in  a  more  mesial  position,  while  the  spine 
i-  moo-  horizontal  than  is  normal.  The  patient  cannot  raise  the  arm  in  the 
forward  direction  above  the  horizontal.     This  lesion  is  distinguished  from 


SUPKASCAPULAE  AND  CIRCUMFLEX  NERVES  687 

the  slight  "  winging  "  of  the  scapula  from  paralysis  of  the  lower  part  of  the 
trapezius  by  the  fact  that  on  attempting  to  thrust  the  arm  forward  against 
a  resistance  the  winging  becomes  more  pronounced,  while  if  due  to  paralysed 
trapezius  (with  normal  serratus)  the  deformity  disappears. 

Treatment.  As  the  lesion  is  incomplete,  recovery,  is  generally  good  if 
the  cause  of  pressure  be  removed,  the  arm  slung,  and  massage  employed. 
Should  the  division  of  the  nerve  be  complete,  suture  may  be  attempted  or 
the  distal  part  of  the  nerve  anastomosed  into  the  posterior  cord  of  the 
plexus,  while  if  this  fail,  part  of  the  pectoralis  major  should  be  transplanted 
into  the  angle  of  the  scapula. 

(2)  The  Sujwascapular  Nerve.  This  supplies  the  spinati,  and  may  be 
injured  by  the  pressure  of  weights  carried  on  the  shoulder.  The  result  is 
impaired  outward  rotation  of  the  humerus,  but  this  is  only  partial,  since  the 


Fig.  2")7.     Wrist-drop  from  musculospinal  palsy,  due  to  the  pressure  of  a  crutch. 

teres  minor  and  posterior  fibres  of  the  deltoid  can  carry  out  this  movement. 
No  treatment  beyond  massage  will  be  needed. 

(.'5)  The  ( 'ire  inn  flex  Nerve.  Injuries  of  this  nerve  are  uncommon  ;  most 
cases  supposed  to  be  of  this  nature,  often  following  falls  on  the  point  of  the 
shoulder,  are  really  injuries  to  the  fifth  cervical  nerve  or  the  upper  trunk 
of  the  plexus,  which  contains  the  circumflex  fibres.  The  circumflex  is 
more  likely  to  be  affected,  as  it  winds  around  the  neck  of  the  humerus, 
from  the  pressure  of  crutches  or  fractures  and  dislocations  of  the  upper  end 
of  the  humerus.  The  deltoid  is  wasted,  but  there  is  not  the  wasting  of  the 
spinati  or  sinking  and  subluxation  of  the  head  of  the  humerus  noted  when 
the  fifth  root  is  affected  ;  moreover,  there  will  be  a  patch  of  ana3sthesia  to 
prick  and  light  touch  over  the  deltoid  insertion. 

Treatment.  The  injury  is  usually  incomplete  and  operation  seldom 
ueeded,  but  if  the  muscle  degenerates  and  its  function  is  not  well  compen- 
sated by  other  muscles  the  nerve  should  be  exposed  by  incision  along  the 
posterior  edge  of  the  deltoid  and  suture  or  anastomosis  performed. 

(4)  The  musculo-cutaneous  uerve  may  be  injured  by  bullet-wounds  or 
in  the  removal  of  tumours,  which  leads  to  paralysis  of  the  biceps,  coraco- 
brachialis,  and  part  of  the  brachialis  anticus.     Flexion  and  supination  of 


\    I  EXTBOOK  OF  SURGERY 


the  forearm  are  weakened  bu1  still  carried  out  by  the  brachialis  anticus  and 
supinator  brevis.  Sensation,  both  epicritic  and  protopathic,  is  lost  over  the 
radial  Bide  of  the  forearm. 

fhe  musculo-spiral  nerve  is  very  often  affected.  Pressure-lesiona 
arise  from  use  of  cratches  or  the  arm  resting  on  the  edge  of  a  table  or  chair 
or  being  over-abducted  in  the  deep  somnolence  of  anaesthesia  or  that  arising 
from  alcoholic  excess.  In  such  instances  the  nerve  is  affected  high  up  ;  it 
may  also  be  injured  in  the  middle  of  the  forearm  in  the  musculo-spiral 


Fig.  259.      Anaesthesia  caused  4by  section  of  the 
musculo-spiral   high   in  the   upper    arm.      Dark 
shading,  protopathic   loss.       Light   shading,   epi- 
critic loss.     (After  Sherren.) 


B 


Kn..  258.     A,  Ordinary  crutch. 

B,  Better  type  of  crutch  with 

hand  rest. 


groove  from  fractures  of  the  humerus,  either  by  being  torn,  pressed  on, 
caught  between  the  fragments  or,  later,  by  growth  of  callus.  Crutch-palsy  is 
avoided  by  ample  padding  on  the  head  of  crutches  and  placing  a  cross-bar 
for  the  hand  half-way  down  to  take  some  of  the  body-weight.  (Fig.  25s.) 
The  danger  of  prolonged  raising  of  the  arms  over  the  head  under  anaesthesia 
has  been  mentioned. 

Motor  Effects.  Commonly  the  triceps  escapes,  and  the  supinators  and 
extensors  of  the  wrist  are  paralysed,  causing  the  wrist  to  be  flexed  and  the 
forearm  pronated  (dropped  wrist)  ;  the  grasp  is  very  weak  from  inability 
to  tighten  the  flexors  by  extending  the  carpus  and  metacarpus:  later, 


I 


MUSCULO-SPIRAL  AXD  ULNAE  NERVES  689 

subluxation  forward  of  the  wrist  may  result.  Where  the  triceps  is  affected 
there  will  be  in  addition  inability  to  extend  the  forearm.  In  the  "  dropped 
wrist  "  resulting  from  chronic  Lead-poisoning  the  supinator  longus  commonly 
escapes. 

Sensory  Changes.  Division  of  the  musculo-spiral  below  its  external 
cutaneous  branches  or  of  the  radial  (its  lowest  cutaneous  branch)  causes  no 
anaesthesia.  Division  above  the  external  cutaneous  branches  causes  loss 
of  protopathx  and  epicritic  sensation  on  the  radial  side  of  the  hand  and 
dorsum  of  the  thumb  (Fig.  £59).  If  the  radial  nerve  be  divided  after 
passing  under  the  supinator  longus  tendon  {i.e.  after  association  with  the 
cutaneous  branches  of  the  musculocutaneous  nerve)  there  will  be  loss  of 
epicritic  sensation  on  the  dorsum  of  the  thumb. 

Prognosis.  Most  instances  of  "  crutch,"  "  Saturday  night,"  and  anaes- 
thetic palsy  show  no  electrical  changes  and  recover  in  a  month  ;  if  there  is 
partial  division  recovery  commences  in  one  to  three  months.  Where  there 
is  reaction  of  degeneration,  recovery  without  operation  is  unusual.  After 
suturing  the  prognosis  is  very  good,  recovery  taking  place  in  four  to  twelve 
months.  This  is  due  to  the  fact  that  the  muscles  supplied  by  this  nerve 
perform  coarse  movements  and  that  there  is  no  anaesthesia.  Where  the 
nerve  is  involved  in  callus  or  between  the  ends  of  the  fractured  humerus 
it  may  be  necessary  to  insert  a  graft  of  radial  nerve  if  much  has  been 
destroyed.  In  all  cases  the  carpus  and  metacarpus  should  be  kept  hyper- 
extended  on  a  splint  to  prevent  stretching  of  the  extensor  muscles  and  daily 
massage  carried  out. 

Exploration  is  practically  only  needed  where  the  nerve  is  involved  in 
fractures.  An  incision  is  made  in  the  course  of  the  nerve  between  the 
supinator  longus  and  biceps,  dividing  the  external  head  of  the  triceps  above 
as  it  arches  over  the  nerve  in  the  musculo-spiral  groove  ;  having  found  both 
ends,  suture  or  grafting  is  performed. 

(())  The  internal  cutaneous  nerve,  if  completely  divided,  causes  loss 
of  epicritic  and  protopathic  sensation  over  the  front  and  back  of  the  ulnar 
border  of  the  forearm  ;  if  one  branch  be  divided  there  is  loss  of  epicritic 
sensation  only  in  the  corresponding  area  of  distribution. 

(7)  The  Ulnar  Nerve.     This  nerve  is  liable  to  injury  at  the  elbow  or  wrist. 

(a)  Injury  at  the  elbow  is  generally  subcutaneous,  from  blows,  fractures 
and  dislocations,  and  it  has  been  injured  in  excisions  of  the  elbow  as  it  lies 
between  the  internal  condyle  and  olecranon.  Division  in  this  situation 
causes  paralysis  of  the  flexor  carpi  ulnaris,  part  of  the  flexor  profundus  and 
all  the  intrinsic  muscle  of  the  hand  lying  to  the  ulnar  side  of  the  long  flexor 
tendon  of  the  thumb  except  the  two  radial  Lumbricals.  The  wasting  of 
the  interossei  is  very  noticeable  later,  as  well  as  the  position  which  is  assumed 
(ulnar  claw),  in  which  the  proximal  phalanges  of  the  index  and  middle 
fingers  are  extended,  those  of  the  ring  and  little  fingers  hyperextended. 
while  the  middle  and  distal  phalanges  of  all  the  fingers  are  flexed,  especiallv 
of  the  ring  and  little  fingers.  On  flexing  the  wrist  this  deviates  radially. 
From  the  paralysis  of  the  interossei  abduction  and  adduction  of  the  fingers 

I  44 


A  TEXTBOOK  OF  Sl'R(!KRY 


PlG.   260.      "  Main  en  griffe,"   characteristic   of  ulnar 
paralysis,  as  regards  position  of  the  fingers  ;   the  wast- 
ing of  all  the  thenar  muscles  shows  that  the  lesion  is  of 
the  inner  end  of  the  plexus,  hut  is  partially  recovered. 


at  their  metacarpophalangeal  joints  is  lost,  as  well  as  true  adduction  of  the 

thumb. 

Sensation.     Epicritic  sensation  is  lost  over  the  little  and  hall  the  ring 

finger  and  the  corresponding  part  of  the  dorsum  and  palm  of  the  hand. 

of  protopathic  sensation    varies,   sometimes   being  confined  to  the 

last  phalanges,  at  others 
being  nearly  as  great  as 
the  epicritic  loss  :  loss  of 
deep  sensation  is  of  the 
same  extent  as  protopathic 
loss. 

(b)  When  the  ulnar 
nerve  is  divided  at  the  wrist 
the  intrinsic  muscles  of  the 
hand  are  paralysed  as  be- 
fore, the  flexor  carpi  ulnaris 
and  flexor  profundus  escap- 
ing. The  loss  of  sensation 
is  the  same  if  the  division 
be  above  the  dorsal  branch,  except  that  deep  sensation  is  not  lost  in  this 
lesion  unless  the  tendons  be  cut  as  well. 

When  the  division  is  below  the  dorsal  branch  the  motor  lesion  is  as 
before,  but  sensory  loss  is  less.  The  epicritic  loss  on  the  palmar  surface  is 
as  for  the  higher  lesion,  but 
on  the  dorsum  only  the  last 
two  phalanges  are  insen- 
sitive to  epicritic  stimuli 
and  deep  sensation  is  not 
affected  at  all,  while  proto- 
pathic loss  varies,  being 
usually  confined  to  the  last 
phalanx  of  the  little  finger. 
(Big.  261.)  _ 

Diagnosis  of  lesions  of 
the  ulnar  nerve  has  to  be 
made  from  those  of  the  inner 
cord  of  the  plexus  and  the 
first  dorsal  root ;  in  both  of 
these  lesions  there  is  com- 
plete paralysis  of  the  intrinsic  muscles  of  the  hand,  resulting  in  the  true 
"  claw-hand  "  with  wasting  of  the  thenar  eminence  and  loss  of  adduction  and 
opposition  of  the  thumb,  while  in  the  case  of  lesions  of  the  inner  cord  there 
will  be  anaesthesia  of  the  inner  side  of  the  forearm  as  well  as  of  the  hand  and 
fingers  :  in  lesions  of  the  first  dorsal  root  sensory  changes  will  be  ill  defined. 
The  full  protopathic  supply  of  the  ulnar  nerve  includes  the  whole  of 
the  ring  and  little  fingers  and  the  palm  and  dorsum  to  between  the  first 


Fig.  261.  A,  Anaesthesia  caused  by  section  of  the  ulnar 
nerve  above  the  dorsal  branch.  Dark  shading,  proto- 
pathic loss.   Light  shading, epicritic  loss.  (After Sherren.) 


ULNAR  NERVE 


G91 


Fig.  202. 


and  second  metacarpals  ;  this  area  will  be  hypersensitive  in  irritative  lesions* 
of  the  ulnar  nerve.     (Fig.  262.) 

Treatment.  Splinting  at  night  with  the  ringer  extended  at  the  phalangeal 
joints  flexed  at  the  metacarpo-phalangeal  joint  (to  prevent  claw-hand 
deformity),  and  massage,  after  suturing  the  divided  nerve,  is  indicated. 

Recovery.  Protopathic  sensation  commences  to  return,  after  division  at 
any  point,  in  six  to  ten  weeks,  and  is  complete  in  five  months  ;  epicritic 
sensation  in  nerves  divided  at  the  wrist  commences  to  recover  in  six  months 
and  is  complete  in  ten  :  if  the  lesion  be  at  the  elbow  recovery  of  epicritic 
sensation  is  much  slower,  taking  two  years.  Motor  power  commences  to 
return  if  division  be  at 
the  wrist  in  one,  but  if  at 
the  elbow  not  for  two, 
years. 

Secondary  suture  gives 
less  satisfactory  results. 
complete  recovery  never 
taking  place. 

Operations  on  the  Ulnar 
Nerve.  The  nerve  may 
be  exposed  above,  behind 
the  internal  condyle  ;  be- 
low, between  the  tendons 
of  the  flexor  carpi  ulnaris 
and  the  flexor  sublimis,  the  artery  lying  to  the  radial  .side  of  the 
nerve. 

Another  form  of  injury  to  the  ulnar  nerve  is  that  occurring  many  years 
after  injuries  to  the  lower  epiphysis  of  the  humerus,  in  which  the  carrying 
angle  of  the  forearm  has  taken  an  exaggerated  valgus  position,  the  nerve 
being  overstretched.  The  nerve  may  not  be  affected  for  twenty  years  or 
more,  when  pains  in  the  area  supplied  by  the  nerve,  followed  by  anaesthesia 
and  paralysis,  result,  while  cubitus  valgus  and  a  swelling  of  the  interna] 
condyle  will  be  found. 

Treatment  depends  on  the  amount  of  division  :  if  incomplete,  a  groove 
may  be  made  for  the  nerve  in  the  condyle  or  the  cubitus  valgus  im- 
proved by  osteotomy  ;  when  the  division  of  the  nerve  is  complete  the 
tuill)  of  the  latter  is  excised  and  the  nerve  sutured,  the  elbow  being  also 
corrected. 

Dislocation  of  the  Ulnar  Nerve.  This  consists  in  abnormal  laxity  in 
attachments  of  the  nerve  associated  with  cubitus  valgus,  whether  of  con- 
genita] or  acquired  origin  ;  the  nerve  may  be  so  mobile  as  to  dislocat  ■  in 
front  of  the  internal  condyle.  The  condition  usually  arises  in  adults  after 
injuries  to  the  elbow,  and  pain  is  found  in  the  ulnar  distribution  with  altera- 
tion of  sensation  and  muscular  weakness  and  wasting  :  these  affection-  are 
relieved  by  rest  but  recur  on  moving  the  joint,  and  the  repeated  injuries 
may  cause  a  thickening  to  appear  on  the  nerve. 

I  !  ! 


Complete  protopathic  supply  of  ulnar  nerve. 
(After  Sherren.) 


- 


A    IKXTBOOK  OK  SlIUiERY 


Treatment.  A  groove  should  be  cut  in  the  back  of  the  internal  condyle 
and  the  nerve  fastened  there  with  a  slip  of  fascia  ;  occasionally  excision 
of  the  damaged  part  and  suture  of  the  nerve  may  be  needed. 

-  / 1-,  M>  dian  Nerve.  This  may  be  divided  at  the  wrist  in  injuries 
with  broken  glass,  less  often  in  the  forearm  or  above  the  elbow  in  fractures, 
punctured  wounds,  pressure  of  traumatic  aneurysms,  &c.  The  following 
paralyses  are  noted  : 

Sensory.  When  the  division  is  at  the  wrist  there  is  loss  of  epicritic 
sensation  on  the  fingers  and  palm  to  the  radial  side  of  the  middle  of  the 
ring  finger,  extending  over  the  front  of  the  thumb,  the  distal  two  phalanges 
of  these  digits  being  involved  on  the  dorsal  surface.  The  area  of  proto- 
pathic  loss  varies  from  the  last  two  phalanges  of  the  first  and  second 


Fig.  263.     A,  True  abduction  of  the  thumb.     B.  False  abduction  of  thumb  (cases 
of  median  paralysis). 


finger  to  nearly  that  of  the  epicritic  loss.  Unless  tendons  are  cut 
there  is  no  loss  of  sensation  of  deep  touch,  which  accounts  for  many  of 
these  cases  being  missed.  When  the  injury  is  at  the  elbow  or  above  this, 
deep  sensation  may  be  affected  as  well,  but  the  other  sensory  loss  is 
unchanged. 

Motor  Effects.  When  divided  at  the  wrist  there  is  paralysis  and  wasting 
of  the  intrinsic  muscles  of  the  hand  to  the  radial  side  of  the  long  flexor  of 
the  thumb  (thenar  eminence),  as  well  as  of  the  two  radial  lumbricals  ;  the 
result  is  that  true  abduction  and  opposition  of  the  thumb  are  lost,  the  thumb 
coming  into  the  same  plane  with  the  fingers  (ape-hand),  though  this  may 
not  be  very  noticeable.  A  spurious  opposition  can  be  managed  by  use  of 
the  long  flexor  and  first  dorsal  interosseus  muscle,  while  false  abduction 
by  means  of  the  long  extensors  can  be  done.  True  abduction  in  a  plane 
at  right  angles  to  the  palm  is  no  longer  possible  (Figs.  263,  264).  If  the 
nerve  be  divided  at  the  elbow,  in  the  arm,  in  addition  to  the  above 
paralyses  there  will  be  loss  of  pronation  and  some  impairment  of  flexion 


THE  MEDIAN  XERVE 


093 


of  the  fingers,  chiefly  of  the  last  phalanges  and  of  the  index  and  ring 
fingers,  which  may  cause  but  little  inconvenience. 

Diagnosis.     This  lesion  is  often  missed  owing  to  the  small  amount  of 
paralysis  and  the  absence  of  gross  anaesthesia  (deep  touch  being  unaffected). 


Fig.  264.     A,  Normal  opposition    of    the    thumb.     B,  Attempt   to   oppose    the 
thumb  when  the  thenar  muscles  supplied  by  the  median   nerve  are   paralysed. 

(See  also  Fig.  250.) 

but  the  affection  is  important  because  much  of  the  comfort  of  daily  life 
and  the  power  of  conducting  finer  occupations — e.g.  fastening  a  collar-stud, 
sewing,  using  pen,  pencil,  or  brush— depends  on  proper  recovery  of  epicritic 


Fig.  265.     Anaesthesia  caused  by  section  of  the  median  nerve.     Dark  shading  shows 
protopathic,  light  shading  epicritic  loss.     (After  Sherren.) 


sensation  in  the  terminal  phalanges  of  the  thumb  and  adjoining  fingers, 
which  is  destroyed  by  section  of  the  median  nerve  and  recovers  poorly  after 
secondary  suture. 

Recovery.    After  primary  suture  protopathic  sensation  begins  to  return 
in  six  to  twelve  weeks  ;    epicritic  sensation  commences  to  return  in  nine 


69 1 


\  TEXTBOOK  »»!•'  SURGERY 


months,  is  complete  in  twelve  months.  II  the  Lesion  be  higher  t be  recovery 
is  less  rapid.     Motor-power  begins  to  recover  in  ten  months. 

The  prognosis  is  better  than  in  ulnar  lesions  because  there  is  not  the 
same  tendency  to  deformity.  The  full  protopathic  supply  of  the  median 
nerve  is  Dearly  the  whole  o!  the  palm  except  a  small  ulnar  strip,  the  palmar 
surface  oi  the  thumb  and  first  three  fingers,  and  the  dorsal  surface  of  these 
fingers  nearly  to  the  metacarpophalangeal  joint  (Fig.  266). 

Operation.  The  nerve  is  found  at  the  wrist  lying  between  the  tendons 
of  the  flexor  carpi  radialis  and  pa  I  maris  longus  muscles. 

\\  here  the  median  and  ulnar  nerves  are  divided  together  there  is  epicritic 

•  oi  responding  to  the  areas  of  the  two  nerves,  while  the  protopathic  loss 
is  nearly  as  great,  only  the  palmar  surface  of  the  thumb  and  adjoining 
-trip  of  palm  receiving  protopathic  stimuli. 


Fig.  -in;.     Complete  protopathic  supply  of  the  median  nerve. 

I  Alter  Sherren.) 

The  Intercostal  Nerves.    These  maybe  affected  in  various  ways  by 

spinal  caries,  aneurysm,  tumours,  herpes  zoster,  &c,  and  may  be  the  seat 
of  neuralgia  (pleurodynia)  :    operative  measures  are  seldom  indicated. 

Injuries  of  the  Cauda  Equina.  The  cauda  consists  of  the  anterior 
and  posterior  roots  of  the  lumbar  and  sacral  nerves  (which  in  their  further 
course  form  the  lumbar  and  sacral  plexuses)  lying  in  their  sheath  of  dura 
mater  ami  extends  from  the  lower  border  of  the  first  lumbar  vertebra 
down  the  sacral  canal,  losing  constituents  as  it  goes.  The  posterior  root 
ganglia  are  outside  the  dura  mater,  so  that  lesions  of  the  cauda  equina  are 
of  anterior  and  posterior  roots  and  not  of  complete  nerves.  The  point  of 
-  of  the  nerves  from  the  dura  is  much  lower  than  their  origin  from 
the  spinal  cord.  The  part  of  the  spinal  cord  below  the  third  sacral  nerve 
(which  is  level  with  the  twelfth  dorsal  vertebra)  is  known  as  the  conus 
m  dullai 

The  cauda  equina  is  liable  to  injury  in  fractures  of  1  he  lumbar  and  sacral 
vertebra?,  while  the  conus  medullaris  will  be  injured  as  well  where  the  spinal 
lesion  is  at  the  dorsi-lumbar  junction.  When  the  lesion  is  incomplete  the 
lower  nerves  suffer  more  than  those  whose  origin  is  higher  ;  thus  affections 
<>1  the  bladder  and  rectum  and  anaesthesia  of  the  buttocks  and  coccyx  are 


LUMBAR  AND  SACRAL  PLEXUSES  695 

nearly  always  present,  corresponding  to  lesions  of  the  third  sacral  and  the 
nei  ves  below  this.  As  in  other  root  lesions,  sensation  for  protopathic  stimuli 
is  lost  over  a  larger  area  than  for  epicritic. 

The  paralysis  is  of  the  lower-segment  type. 

The  muscles  supplied  by  the  roots  are  as  follows  : 

Third  and  Fourth  Sacral.  Levator  ani,  sphincter  ani.  and  perineal 
muscles. 

Second  Sacral.     Glutei  and  hamstrings. 

First  Sacral  (internal  popliteal  nerve).  The  intrinsic  muscles  of  the  foot, 
the  posterior  tibial  muscles,  including  those  of  the  calf. 

Fifth  Lumbar.  The  antero-external  muscles  of  the  leg,  i.e.  those  supplied 
by  the  external  popliteal  nerve  with  the  exertion  of  the  tibialis  anticus. 

Fourth  Lumbar.  The  extensors  of  the  leg  (quadriceps  femoris)  and 
tibialis  anticus. 

Asymmetrical  distribution  of  paralysis  and  anaesthesia  suggests  lesions 
of  the  cauda  equina,  as  do  sensory  changes  characteristic  of  nerve-root 
lesions,  as  opposed  to  those  found  when  the  cord  is  affected. 

Diagnosis  of  lesions  of  the  cauda  equina  is  important  because  suture  of 
divided  nerves  (at  any  rate  of  the  anterior  roots)  is  likely  to  be  successful 
(the  posterior  roots,  being  divided  above  the  ganglia,  are  not  likely  to 
regenerate).  Hence  if  there  is  reason  to  suspect  such  lesion,  laminectomy 
should  be  done  and  the  nerves  investigated,  suture  being  performed. 

The  lumbar  and  sacral  plexus  are  seldom  affected  as  a  whole,  though 
branches  may  be  injured  in  fractures  of  the  pelvis,  gunshot  wounds,  and 
during  parturition.  True  neuralgia  of  the  loin  and  testis  may  occur,  though 
this  is  far  less  usual  than  pain  referred  from  the  kidney. 

Branches  of  the  Lumbar  and  Sacral  Plexuses.  (1)  The  anterior 
crural  nerve  may  be  affected  in  fractures  of  the  pelvis,  bullet-wounds, 
operations  (as  on  psoas-abscess).  The  resulting  paralysis  is  of  the  quadriceps 
femoris,  while  sensory  loss  is  well  defined  on  the  inner  lower  part  of  the  leg 
above  and  below  the  internal  malleolus,  corresponding  with  the  distribution 
of  the  internal  saphenous  nerve,  to  both  epicritic  and  protopathic  stimuli, 
as  well  as  an  ill-defined  area  over  the  anterior  and  inner  aspect  of  the  thigh, 
where  the  loss  is  incomplete. 

(2)  The  obturator  nerve  is  rarely  injured,  byprotracted  labour,  in  thyroid 
dislocation  of  the  hip  and  obturator  hernia.  The  result  is  paralysis  of  the 
adductors  except  the  long  hamstring  portion  of  the  adductor  magnus,  and 
no  loss  of  sensation. 

(.'))  The  external  cutaneous  nerve  is  rarely  divided,  causing  loss  of  epicritic 
and  protopathic  sensation  of  the  upper,  outer  part  of  the  thigh.  A  well- 
recognized  condition  is  caused  by  neuritis  or  neuralgia  of  this  nerve 
(Bernhardt),  consisting  of  pain  and  alteration  of  Bemation  over  its  dis- 
tribution. This  appears  to  be  due  to  pressure,  e.g.  from  an  ill-fitting  truss 
or  from  the  nerve  being  nipped  by  muscular  contraction  as  it  emerges  from 
the  deep  fascia. 

Signs.    Tingling  and  pain  along  the  course  ol  the  nerve,  increased  on 


A  TEXTBOOK  OF  SURGERY 

ise  oi  the  leg  and  Blight  alteration  of  sensation  ;  while  later  a  swelling 
may  be  fell  in  the  course  of  the  nerve. 

Treatment.  Removal  of  the  cause  if  discovered,  and  application  of 
constant  electric  current  ;  failing  this,  exploration,  removal  of  the  bulb  on 
thf  nerve,  and  suture. 

(4)  The  long  saphenous  nerve  may  be  injured  in  operations  for  varicose 
veins,  fractures  of  the  tibia,  or  tying  the  femoral  artery  in  Hunter's  canal. 

(5)  The  gluteal  nerve  may  be  pressed  on  by  aneurysm  of  the  gluteal 
artery  but  is  seldom  affected  alone,  more  usually  in  lesions  of  the  cauda 
equina,  producing  weakness  and  wasting  of  the  buttock  and  inability  when 
lying  on  the  face  to  extend  the  thigh  on  the  body. 

(6)  The  Great  Sciatic  Nerve.  This  nerve  is  usually  injured  by  bullet- 
wounds,  occasionally  in  dislocations  of  the  hip  or  attempts  to  reduce  them. 

In  the  case  of  bullet-wounds  the  division  is  often  incomplete,  and  most 
usually  affects  the  peroneal  (external  popliteal)  portion.  The  sciatic  must 
be  regarded  as  two  nerves,  the  external  and  internal  popliteal  (lying  in  the 
same  sheath),  one  of  which  may  be  injured  without  the  other,  and  thus 
the  results  are  different  from  partial  division  of  other  nerves. 

(a)  Complete  Division  of  the  Great  Sciatic  Nerve.  The  motor  effects  are 
paralysis  of  all  the  muscles  of  the  leg  and  foot,  and  where  the  lesion  is  high 
np  the  hamstrings  may  be  paralysed  as  well.  This  does  not  completely 
prevent  flexion  of  the  thigh,  as  this  movement  can  be  carried  out  by  the 
gracilis.  Sensation  to  all  forms  of  stimuli,  including  deep  touch,  is  lost 
over  the  sole  and  most  of  the  dorsum  of  the  foot,  while  protopathic  and 
epicritic  sensation  are  lost  over  most  of  the  outer  side  of  the  leg,  the  former 
to  the  greater  extent. 

Prognosis  after  Suture.  Deep  touch  is  regained  in  three  to  six  months. 
Protopathic  sensation  commences  to  return  in  two  months  but  takes  many 
months  to  be  complete,  while  epicritic  sensation  does  not  commence  to 
recover  for  twelve  to  eighteen  months.  Motor  recovery  begins  in  the  ham- 
strings after  a  year,  in  the  leg-muscles  after  two  years,  while  for  complete 
recovery  at  least  three  years  are  needed. 

While  the  nerve  is  recovering  after  suture,  overstretching  of  the  ham- 
strings is  prevented  by  keeping  the  knee  flexed  in  a  bucket-stump  for 
walking  and  splinting  the  foot  to  prevent  equinus  deformity.  Suture  of  the 
nerve  is  indicated  quite  late  in  the  case,  as  even  if  the  muscles  do  not  recover, 
the  protopathic  restoration  will  prevent  the  formation  of  trophic  ulcers. 
"Where  motor-power  is  poor  a  walking-instrument  will  be  needed  or  arthro- 
desis of  the  ankle. 

(b)  The  External  Popliteal  Nerve.  This  nerve  is  the  most  usually  affected 
of  any  in  the  lower  limb,  whether  from  bullet- wounds  of  the  sciatic,  tenotomy 
of  the  biceps  femoris  (which  should  for  this  reason  always  be  done  by  open 
incision),  injuries,  operations,  and  splints  about  the  neck  of  the  fibula  or 
pressure  about  the  upper  part  of  the  leg,  e.g.  Clover's  crutch  for  the  litho- 
tomy position,  over-tight  bandages,  puttees,  &c. 

The  anterior  cord-cells  supplying  most  of  this  nerve  are  often  affected 


SCIATICA  697 

in  infantile  paralysis,  in  which  case  the  tibialis  anticus  is  likely  to  escape 
owing  to  the  different  origin  of  this  nerve  in  the  cord. 

Motor  Signs.  Owing  to  the  paralysis  of  the  tibialis  anticus,  extensors 
of  the  toe  and  peroneal  muscles,  the  deformity  of  talipes  equino-varus  will 
result.  The  sensory  loss  is  small  and  confined  to  the  dorsum  of  the  foot 
for  protopathic  and  epicritic  stimuli,  and  to  the  outer  side  of  the  lower  part 
of  the  leg  as  well  for  epicritic,  but  if  injured  above  the  lateral  cutaneous 
branch  loss  of  epicritic  and  protopathic  sensation  extends  most  of  the  way  up 
the  outer  side  of  the  leg.  Recovery  after  suture  is  slow,  taking  three  years, 
the  tibialis  anticus  being  the  first  muscle  to  act. 

The  nerve  is  explored  behind  the  biceps  tendon,  extending  the  incision 
down  and  forward  over  the  neck  of  the  fibula.  A  walking-instrument  will 
be  needed  with  toe-raising  spring  and  varus  T-strap,  to  prevent  deformity 
till  the  muscles  are  recovered. 

Diagnosis  of  injuries  of  the  external  popliteal  nerve  from  lesions  of  the 
peroneal  part  of  the  sciatic  nerve  and  of  the  fifth  lumbar  root.  The  external 
wound,  &c,  will  show  whether  the  lesion  is  in  the  nerve  before  or  after  it 
leaves  the  sciatic  sheath.  In  lesions  of  the  fifth  root  (anterior  polio- 
myelitis) the  tibialis  anticus  escapes,  and  if  only  the  anterior  root  be  injured 
there  is  no  loss  of  sensation,  while  if  the  posterior  root  be  divided  the 
protopathic  is  greater  than  the  epicritic  loss. 

(c)  The  Internal  Popliteal  Nerve.  This  may  be  caused  by  forcible 
extension  of  a  fixed,  flexed  knee.  The  results  are  paralysis  of  the  posterior 
tibial  and  calf  muscles,  causing  dropping  of  the  heel  or  paralytic  talipes 
calcaneus,  and  loss  of  epicritic  and  protopathic  sensation  over  the  sole  of 
the  foot.  The  nerve  may  be  exposed  in  the  middle  of  the  popliteal  space, 
where  it  is  the  most  superficial  structure,  and  sutured  or  anastomosed  with 
part  of  the  external  popliteal  nerve  as  indicated. 

Sciatica.  This  troublesome  and  extremely  painful  affection  is  usually 
due  to  neuritis  of  the  sciatic  nerve,  its  constituents  or  branches,  the  nerve 
being  red  and  congested,  later  thickened  ;  less  commonly  the  nerve  may 
be  the  seat  of  true  neuralgia. 

Many  causes  are  said  to  underlie  this  condition,  some  on  good 
evidence,  others  on  the  poorest.  A  history  of  exposure  to  cold  and  damp, 
of  rheumatism  or  gout,  may  be  to  hand  ;  pressure  of  tumours  of  the  pelvic 
wall,  ovary,  or  rectum  account  for  some  cases  (in  all  cases  of  sciatica  the 
rectum  and  vagina  should  be  carefully  examined).  Chronic  arthritic 
changes  in  the  hip-joint  and  vertebrae  seem  to  be  responsible  in  some  instances 
as  well  as  syphilis. 

Signs.  There  is  constant  pain  down  the  back  of  the  thigh,  radiating  in 
the  more  severe  instances  to  the  leg  and  buttock.  The  pain  is  increased  bv 
stretching  the  nerve,  so  that  the  knee  is  flexed  and  the  patient  walks  on  tip- 
toe to  relax  the  strain  :  at  times  there  are  paroxysmal  exacerbations  of  the 
pain.  Later  cramps,  fibrillary  twitchings  of  muscles,  and  atrophy  occur, 
but  the  reaction  of  degeneration  is  seldom  present  in  the  muscles  supplied. 

On  examination  tenderness  will  be  noted  along  the  course  of  the  nerve. 


\  TEXTBOOK  OF  SURGERY 

Diagnosis  has  to  be  made  from  pressure  <>n  the  nerve  in  the  pelvis  or 
vertebra]  column  and  cord,  by  examining  the  rectum,  and  by  radiographic 
examination  of  the  vertebrae. 

Examination  should  be  made  for  anaesthesia,  paralysis  and  the  reaction 
of  degeneration,  which  point  to  tumours  of  the  cord  or  cauda  equina,  and 
the  lightning-pains  of  tabes  are  excluded  by  their  short  duration  and  a 
general  examination  of  the  uervous  system. 

Treatment.  The  surgeon  is  seldom  called  in  before  the  patient  has 
(I  through  the  whole  gamut  of  medical  treatment,  including  rest  on  a 
long  splint  with  extension  ;  counter-irritants  such  as  blisters  or  acu- 
puncture ;  specific  remedies,  such  as  iodides,  aspirin  ;  electrical  treatment, 
high  frequency  and  the  constant  current;  massage;  and  various  hydro- 
therapy methods,  especially  hot-air,  brine,  and  mud-baths — any  of  which 
may  give  relief  and  under  any  of  which  the  disease  may  become  arrested, 
though  whether  on  account  of  the  treatment  or  because  at  the  time  that 
any  particular  treatment  is  being  applied  the  disease  comes  to  a  natural 
termination  is  uncertain,  to  say  the  least.  Of  surgical  measures  nerve- 
>t  retching  may  be  employed  in  cases  of  some  standing,  since  this  undoubtedly 
relieves  at  times,  though  recurrences  are  only  too  frequent.  To  begin  with, 
stretching  should  be  done  "  bloodlessly,"  by  angesthetizing  the  patient  and 
flexing  the  thigh  fully  on  the  abdomen  with  the  leg  extended.  Should  this 
measure  fail,  the  nerve  may  be  exposed  below  the  gluteus  maximus  by  a 
Longitudinal  incision  midway  between  the  tuber-ischii  and  the  great  tro- 
chanter, drawing  the  hamstrings  inward.  The  nerve  is  then  freed  from 
its  surroundings  up  to  the  sciatic  notch  and  dowrn  as  far  as  possible  and 
well  pulled  up,  but  not  wnth  sufficient  force  to  drag  the  patient  from  the 
operating-table.  Like  other  measures,  this  is  worth  a  trial,  but  is  by  no 
means  an  infallible  cure. 


INDEX 


INDEX 


Abbe  (string-saw  for  stricture  of  oesophagus), 

ii.  400 
Abbott,  treatment  of  scoliosis,  i.  4-"..") 
Abdomen,  "acute,"  diagnosis,  ii.  113 

gunshot  wounds  of,  ii.  107 

injuries  of.  ii.  lor, 

rupture  of  viscera,  ii.  108 

upper,  examination  of,  ii.  131 

wounds  of,  ii.  107 
Abdominal  operations,  after-treatment  of,  ii. 
96 

closure  of.  ii.  95 

drainage  in,  ii.  95 

incisions,  ii.  91 

position  in,  ii.  90 

preparation  for.  ii.  89 
Abortion,  tubal,  ii.  338 
Abscess.     <s'"  o^o  Suppuration 

acute,  i.  34 

alveolar,  ii.  403 

anatomy  of,  i.  33 

appendix,  ii.  207,  Lies.  216 

axillary,  ii.  79 

hone.  i.  369 

breast,  ii.  672 

Brodie's,  i.  369 

cerebral  and  cerebellar,  i.  626—630 

chronic  or  cold.  i.   34. 

Abscess,  tuberculous 
cold  (tuberculous),  treatment  of,  i.  191 
extradural,  i.  620 

in,  ii.  79 
ischio-rectal,  ii.  330 
kidney,  ii.  .~>44 
liver,  ii.  169 
lumbar,  i.  442 
lung.  ii.  208 
lymph  nodes,  ii.  79 
mastoid,  i.  615 
neck,  ii.  80 
orbital,  ii.  368 
i.t  [tic  cerebral,  i.  626  630 
palmar,  i.  484 
parotid,  ii.  437 
pelvic,  ii.  1 19 
peri-anal,  ii.  330 
peri-nephric,  ii.  545 
peri. tonsillar  (quinsy),  ii.  1  13 
periurethral,  ii.  626 
prostate,  ii.  590 
psoas,  i.  441 
pyemic,  i.  161 
rectal,  pelvic,  ii.  330 

submucous,  ii.  330 
retropharyngeal  (spinal),  i.  1  in 
retropharyngeal,  ii.  44s.  449 

dp,  i.  501 
signs  of,  i.  '■'<'< 
spinal,  i.  I  to 


Abscess,  spleen,  ii.  193 

stomach,  ii.  136 
sublingual,  ii.  426 

subphrenic,  ii.  120 

tongue,  ii.  422 

treatment  of  acute,  i.  37 
of  cold,  i.  39 

"tropical"  (liver),  ii.  169 

tuberculous,  ii.  188,  191 
A.C.E.  (anaesthetic),  i.  137 
Acetabulum,  fractures,  i.  304 

""  travelling.'"  i.  501 
Acetone  in  urine,  i.  118 
Achondroplasia,  i.  351 
Acidosis,  i.  118 

treatment  of,  i.  119 
Acromegaly,  i.  357 
Acromio-clavicular    joint,     injuries     of,    i. 

26.-. 
Acromion,  fractures,  i.  265 
Actinomycosis,  i.  193 

jaw.  ii.  407 

neck,  ii.  404 
'"  Acute  abdomen,"  ii.  113 
Adenoids,  ii.  394 
Adenoma,  i.  82 

Adrenalin,  for  hemorrhage,  ii.  7 
After-treatment  of  operations,  i.  153 

abdominal,  ii.  96 
Agglutination,  i.  157 
Air-embolism,  ii.  15,  20,  21 
Air-hunger  (in  haemorrhage),  ii.  4 
Albee,  operation  for  spinal  caries,  i.  447 
Albuminuria,  ii.  499 
Alcoholism,  i.  117 
Alexine,  i.  157 
Alveolar  abscess,  ii.  403 
Amputation,  for  aneurysm,  ii.  33 

ankle,  i.  535.  536 

arm.  i.  471 

division  of  soft  tissue-,  i.  431 

elbow,  i.  475 

for  fracture-,  i.  240 

for  gangrene,  i.  63,  66 

for  osteomyelitis,  i.  369 

general  considerations,  i.  128 

hip,  i.  511 

inteiilio-ahdominal.  i.  490 

leg,  i.  531 

length  of  Haps,  i.  432 

id-tarsal),  Chopart,  i.  555 

Pirogoff,  i.  535 

section  of  bone,  i.  433 

shoulder,  i.  468 

subasl  ragaloid,  i.  536 

S\  me's  (ankle  .  i.  53  t 

■metatarsal    (Lisfranc,     Hey.    Skey), 
i.  556 

techniipie.  i.  429 


INDEX 


Amputation,  thigh,  i.  f>14 

tuberculous  joints,  i.  410 
upper  limb  (Berger),  i.  169 

wrist,  i.  479 
Amyloid  degeneration,  i.  43 
Anaerobes,  i.  '•• 
Anaesthesia,  administration  of,  i.  136 

after-treatment,  i.  14(1 

chloroform,  i.  137 

choice  of  method,  i.  143 

difficulties  of,  i.  139 

ether,  i.  137 

ethyl  chloride,  i.  138 

intratracheal     insufflation,    i.     138 

695 
intravenous,  i.  143 
local,  i.  140 
methods,  i.  135 
mixtures,  i.  137 
nerve  blocking,  i.  140 
nitrous  oxide,  i.  130 
preparation  for,  i.  135 
spinal,  i.  141 
Anal  fissure,  ii.  329 
Anastomosis  of  blood-vessels,  ii.  48 
intestinal  end-to-end,  ii.  99 
end-to-sidc.  ii.  105 
lateral,  ii.  101 
Murphy's  button,  ii.  105 
nerves,  i.  664,  679 
of  viscera,  ii.  99 
Anel,  treatment  of  aneurysm,  ii.  29 
Aneurysm,  aorta,  descending,  ii.  34 
aortic  abdominal,  ii.  34 

arch,  ii.  33 
axillary,  ii.  37 
carotid,  common,  ii.  35 
external,  ii.  35 
internal,  ii.  35 
causes  of,  ii.  24 
cirsoid,  i.  90,  502  ;  ii.  46 
diagnosis  of,  ii.  28 
femoral,  ii.  38 
gluteal,  ii.  37 
inguinal  and  iliac,  ii.  37 
innominate,  ii.  35 
intracranial,  i.  36 
orbital.     See  retro-orbital 
popliteal,  ii.  38 
retro-orbital,  ii.  31 
signs  of,  ii.  27 
structure  of,  ii.  25 
subclavian,  ii.  30 
terminations  of,  ii.  26 
traumatic,  ii.  17,  18,  19 
treatment  of,  ii.  29-33 

acupuncture,  ii.  :;i 

amputation,  ii.  33 

complications,  ii.  33 

electrolysis,  ii.  31 

excision,  ii.  31 

general,  ii.  29 

ligature,  ii.  29 

Matas's  operations,  ii.  31,  32 

new  operation  (Matas),  ii.  31 

old  operation  (Antyllus),  ii.  ::i 

pressure,  ii.  29 

wiring,  ii.  .:l 
varicose,  ii.  21,  22 
varieties  of,  ii.  ^'"i 


Aneurysmal  varix,  ii.  21.  22 
of  cavernous  ^inus. 

v     Aneurysm,  retro-orbital 
Angeioma,  i.  89 

arterial,  i.  90  ;   ii.  4('t 

capillary,  i.  '.Hi ;  ii.  1". 

lymphatic,  i.  90 
Ankle,  acute  inllammat  ion,  i.  ■">:'.:_' 

amputations,  i.  534 

Charcot's,  i.  533 

dislocations,  i.  343 

fractures  about,  i.  338 

operations  on,  i.  .">:;:! 

rheumatoid,  i.  533 

tuberculosis,  i.  532 
Ankylosis,  i.  395 

hip,  i.  509 

treatment,  i.  397 
Anosmia,  ii.  357 
Anthrax,  i.  1  Tr. 
Anti-bacterial  sera,  i.  18 
Anti-bodies,  i.  17 
Antisepsis,  i.  144 
Antiseptics,  chemical,  i.  145 
Antitoxic  Bera,  i.  28 

Antrum  of    Hiirhmore  (jaw),    affections,   ii. 
391 

mastoid,  i.  614-620.     Sec  Mastoid 

maxillary,  ii.  391 
Antyllus,  treatment  of  aneurysm,  ii.  31 
Anuria,  ii.  506 

calculous,  ii.  523 

signs  and  treatment,  ii.  533 
Anus,  artificial,  pros  and  con<.  ii.  l'l".i 

imperforate,  ii.  329 

pruritus  ani,  ii.  328 
Aorta.     Sec  Aneurysm  of 
Apoplexy,  i.  596.     See  Brain 
Appendicectomy,  "  interim."  ii.  216 
Appendicitis,  abscess,  ii.  2(i(i.  208,  214 

aetiology,  ii.  204 

anatomy,  ii.  204 

children,  ii.  210 

chronic  (varieties),  ii.  210 

colitis  type,  ii.  211 

complications  of,  ii.  216,  217 

diagnosis,  ii.  209 

dyspeptic  type,  ii.  211 

intestinal  obstruction  from,  ii.  217 

rectal  examination,  ii.  208 

results  of,  ii.  206 

signs  of  (acute),  ii.  207 

treatment  of,  abscess,  ii.  214 
acute,  ii.  212 
Appendicostomy,  ii.  202 
Appendicular  gastralgia,  ii.  211 
Appendix  vermiformis,  ii.  203 
cases  of,  ii.  218 

operations,  ii.  212-216 

position,  ii.  203 
Arachnoid  cyst,  i.  595 
Arachnoiditis,  i.  < '21.     8a   Brain 
Arm,  amputation  through,  i.  471 
Arteries,     carotid,     internal,      intracranial 
rupture,  i.  593 

degeneration  of,  atheroma,  ii.  21 
calcareous,  ii.  24 

inflammation  of.  infective,  ii.  23 
plastic,  ii.  23 
syphilitic,  ii.  23 
tuberculous,  ii.  23 


INDEX 


Arteries,  injuries  of,  open,  ii.  18 
Bubcutaneous,  ii.  17 
ligature  of,  ii.  49,  6] 

a  oil  a,  ii.  62 
axillary,  ii.  58 
brachial,  ii.  60 
carotid,  ii.  .">_' 
external  carotid,  ii.  .35 
facial,  ii.  55 
femoral,  ii.  63,  64,  65 

superficial,  ii.  Go 
iliacs,  ii.  62,  63 
interior  thyroid,  ii.  58 
innominate,  ii.  51 
internal  mammary,  ii.  097 
Lingual,  ii.  55 
occipital,  ii.  55 
peroneal,  ii.  69 
popliteal,  ii.  lib' 
radial,  ii.  (31 

bclavian,  ii.  56 
temporal,  ii.  50 
tibia]  anterior,  ii.  07 

posterior,  ii.  07 
ulnar,  ii.  61 
vertebral,  ii.  57 
pulmonary,  surgery,  ii.  7nl 
.stay  knot  for,  ii.  50 
suture  of,  ii.  17 
wounds  of,  ii.  18,  19 
Arterio-sclerosis,  ii.  24 
Arterio- venous  anastomosis,  ii.  21,  4s 

wounds,  ii.  21 
Arthrectomy,  i.  1 1 9.     8*  t  Excision 

for  tubercle,  i.  409 
Arthritis,  i.  390 

acute,  i.  393 

ankle,  i.  532 

chronic,  i.  395 

deformans,  i.  413.     -s'- •  Osteo-arthritis 

elbow,  i.  472 

hip,  i.  199 

knee,  i.  515 

rheumatoid,  i.  412 

shoulder,  i.  404 

varieties  of,  i.  400-416 

wrist,  i.  478 
Arthrodesis,  i.  420,  553 
Arthroplasty  (Murphy),  i.  397,  419 
Artificial  limbs,  i.  434 
Ascites,  chylous,  ii.  70,  126 

treatment,  ii.  127 
Asepsis,  i.  144 

urinary,  ii.  506 
Aseptic  technique,  i.  150 
Asphyxia,  traumatic  (compression  cyan 

ii.  095 
Asthma,  secondary  to  rhinitis,  etc.,  ii.  :JS4, 

386 
Astragalus,  dislocai  ion,  i.  344 
ton,  ii.  533 

fracture,  i.  346 

tuberculosis,  i.  532 
Atheroma,  ii.  24 
Atlas,  dislocation,  i.  646 
Atrophy,  i.  5,  13 
Auer  and  Meltzer,  intratracheal  anaesthesia, 

i.  138 
Axillary,  abscess,  ii.  79 

artery,  ligature  of,  ii.  58J 

aneurysm,  ii.  37 


Babinski,  plantar  reflex,  i.  686 
Bacilluria,  ii.  538,  539 
Bacillus  aerogenes  capsulatis,  i.  177 
in  gangrene,  i.  05 

anthracis,  i.  175 

coli,  i.  171 

diphtheria,  i.  179 

Ducrey's,  i.  173 

leprosy,  i.  194 

malignant  oedema,  i.  177 

Mallei  (glanders),  i.  17:j 

tetanus,  i.  180 

tubercle,  i.  Is 5 
Bacteria,  i.  7 

bacillaemia,  i.  14 

conditions  of  life,  i.  8 

distribution  of,  i.  9 

immunity,  i.  15,  17 

investigation  of,  i.  10,  11 

Koch's  postulates,  i.  12 

pathogenic,  i.  12 

products  of,  i.  9 

reproduction,  i.  8 

saprajmia,  i.  14 

spores,  i.  8 

varieties,  i.  7 

varieties  of  infection  with,  i.  13 
Baker's  cysts  (joints),  i.  399 
Ballance,  mastoidectomy,  i.  620 
Balanitis  (gonorrhoea),  ii.  613 
Bankart,  operation  on  cervical  ribs,  i.  458 
Banti's  disease,  ii.  194 
Barnard,  subphrenic  abscess,  ii.  121 
Basedow's  disease  (exophthalmic  goitre),  ii. 

4 '.14 
Bassini.  femoral  hernia,  operation,  ii.  298 

inguinal  hernia,  operation,  ii.  297 
Beck,  treatment    of    sinuses  with   bismuth 

paste,  i.  40 

Bedsores,  i.  54.  oo 

Bennett,    fracture,    metacarpal    of     thumb, 

i.  298 
Berger,  "  fore-quarter  "  amputation,  i.  409 
Bernhardt,    neuritis    of    external   cutaneous 

nerve  (thigh),  i.  695 
Berry,  exophthalmic  goitre,  ii.  495 
Biceps  humeri,  rupture  of,  i.  280 
Biers  congestive  treatment  for  gonorrheal 

joints,  i.  4(  i4 
Bigelow,  dislocation  of  hip,  i.  307J 
Bile-ducts,  drainage  of,  ii.  181-189 

stones  in,  ii.  178,  183 
Bilharzia  hsematobia,  infection  of  bladder, 

ii.  577 
Biliary  calculi,  ii.  174.     See  Gall-stones 
colic,  ii.  170 

passages,  anatomy,  ii.  172 
I  lall- bladder 
calculous  obstruction,  ii.  177 
cancer,  ii.  180,  181 
cholangitis,  ii.  180 
cholecystitis,  ii.  179 
empyema,  ii.  177 
exploration,  ii.  173 
injuries  of,  ii.  173 
mucocele,  ii.  177 
operations  on,  ii.  181-18-* 
tumours,  ii.  180,  181 
Bishop,  hernia  operation,  ii.  290  J 
Bladder,  anatomy,  ii.  558 
atony,  ii.  586^ 


6 


INDEX 


Bladder,  Bilharzia  infection,  ii.  577 

calculi,  ii.  "'til   572 
signs,  ii.  505 
treatment,  ii.  567-  572 

Lithotomy,  litholapaxy 

congenital      defects,     ectopia,     allantoic 
i  j  sts,  and  fistulas,  ii.  559 

diverticula,  ii.  578 

excision  of  (for  tumour),  ii.  583 

Ostitis,  ii.  583 

foreign  bodies,  ii.  563 

functional  derangements,  ii.  584  587 
S     Micturit  ion 

infections  of,  ii.  572  578 
Si  i  Cystitis 

injuries,  ii.  ">oi 

tuberculosis,  ii.  576 

tumours  of.  ii.  579  583 

ulcers,  ii.  578 
Blastomas,  i.  69 

autochthonous,  i.  79 

teratogenous,  i.  79 
Bloodgood,  hernia  operation,  ii.  293 
Blood-vessels,  operations  on,  ii.  47.  etc. 
Boils,  i.  104,  165 
Bones,  achondroplasia,  i.  351 

acromegaly,  i.  357 

atrophy,  i.  349 

caries,  i.  349.  372 

chondroma,  i.  380 

contusions  of,  i.  219 

cretinism,  i.  360 

cysts  of  (v.  Recklinghausen),  i.  384 

diaphysitis,  i.  303-309 

epiphysitis,  i.  304-300 

fibro-sarcoma,  i.  3n4 

fractures  of,  i.  220.     Set  Fractures 

grafting,  i.  389 

gumma,  i.  375 

hydatids  of,  i.  376 

infantile  scurvy,  i.  357 

infection,  juxta-epiphysial,  i.  363,  etc. 

infections,  pyogenic,  i.  301 

leontiasis  ossea,  i.  360 

lipoma  of,  i.  380 

mollities  ossium  (adolescent  type),  i.  357 

necrosis,  i.  348,  365 

new  growths,  i.  379 

operations  on,  i.  387 

OSteitis,  acute,  i.  3112 

deformans,  i.  360 

arthropathy,  pulmonary,  i.  359 
osteogenesis  imperfecta,  i.  351 
osteoma  of,  i.  .'(79 
osteomalacia,  i.  359 
osteomyelitis,  acute,  i.  363 
pathology,  i.  348 
periostitis,  i.  362 
physiology,  i.  347 
pulsal  ing  tumours,  i.  385 
rarefacl  ion,  i.  3  18 
repair  of  defects,  i.  359 

1 1  ion  of,  i.  388 
rickets,  i.  351 

(delayed),  i.  356 
•  .ma.  myeloid,  i.  382 

periosteal,  i.  381 
sclerosis,  i.  :;  is 
"  stopping,"  i.  389 

for  chronic  abscess,  i.  371 
syphilis,  i.  374 


Bones,  tuberculosis,  i.  371 

tumours,  secondary,  i.  387 

typhoid  infect  ion  of,  i.  378 
Boric  acid.  i.  I  17 
Bougie,  oesophageal,  ii.  459 

rectal,  ii.  321,  335 

urethral,  i  i.  507,  017 
Bow-leg,  i.  522 
Box-splint,  i.  313,319 

abduct  ion,  i.  316 
Brachial  artery,  ligature,  ii,  60 

plexus,  injuries,  i.  683  685 
Bradford  s  frame  (spinal  caries),  i.  I 13 
Brain,  abscess,  i.  626  030 
S     <  ierebral  abs 

anatomy  and  physiology,  i.  579 

apoplexy,  i.  596 

Indicts  in.  i.  599 

"  cerebral  irritation,"  i.  589 

compression  (acute),  i.  .390  -592 

concussion,  i.  587-  589 

cortical  centres,  i.  587 

••  decompression  "  for  tumour,  i.  <i.;7 

diagnosis  (general),  i.  582,  583 

epilepsy,  i.  037,  038 

examination  of  eases,  i.  585 

exploration  of,  i.  585 

extradural  haemorrhage,  i.  593 

focal  signs  of  laceration,  i.  597 

hernia  cerebri,  i.  631 

hydrocephalus,  i.  03s 

inflammation,  i.  600,  626 

intracerebral  haemorrhage,  i.  596 

intracranial  haemorrhage,  i.  .V.i2 

intradural  haemorrhage,  i.  5'.I4.  595 

laceration,  i.  597 

lepto-meningitis,  i.  621,  022 

pachymeningitis,  i.  o2o 

subdural  abscess,  i.  023 

thrombosis,  cavernous  sinus,  i.  024 
lateral  sinus,  i.  024 
operation,  i.  025 
longitudinal  sinus,  i.  623 

topography,  i.  579 

tumours,  i.  035 

wounds  (penetrating),  i.  598 
Branchial  cancer,  ii.  485 

cyst,  i.  366 

fistula,  i.  300 
Brasdor,  treatment  of  aneurysm,  ii.  29 
Breast    St  <  also  Nipple 

abscess,  acute,  ii.  072 
chronic,  ii.  072 

anatomy,  ii.  665 

(  ancer,  i  i.  679  693 
diagnosis,  ii.  686 
spread,  ii.  682 
treatment,  ii.  688   693 
varieties,  ii.  680,  683 
j'idtal  defeets,  ii.  667 

cysto-adenoma,  i  i.  070.  077 

cysts,  ii.  674,  075 

duct  papill a,  ii.  078 

examination,  ii.  007 

fibro-adenoma,  i i.  675 

fibro-cysl  ic  degeneration,  ii.  073 

galactocoeles,  ii.  075 

hyperplasia,  ii.  070 

inflammation,  ii.  671-673.     Set  .Mastitis 

involution,  ii.  073 

male,  affections  of,  ii.  090 


rxrEX 


Breast,  mastitis,  chronic  interstitial,  ii.  673 

ii'  uralgia,  ii.  675 

operation  for  cancer,  ii.  688  693 

operations,  ii.  090 

sarcoma,  ii.  078 

syphilis,  ii.  673 

tuberculosis,  ii.  073 

tumours,  ii.  675-693 
Broad  ligament,  cysts  of,  ii.  348 
Brodie,  chronic  abscess  of  bone,  i.  309 
lil>ia.  i.  529 

Bronchiectasis,  ii.  709 
Bronchoscope,  ii  453 
Bronchus,  foreign  bodies,  ii.  465 
Brophy,  cleft-palate  operation,  ii.  361 
Bryant,  •■gallows'"  splint,  i,  319 

measurement  of  hip,  i.  306 
Bubo,  indolent,  i.  199 

Bubonocele,  ii.  278 

Bullet-wounds,  abdomen,  ii.  107 

brain,  i.  599 

in  general,  i.  12(3-127 
Burns,  corrosive  Liquids,  i.  132 

degrees  of,  i.  129 

electrical  discharge,  i.  132 

from  X-rays,  i.  132 

shock  in,  i.  129 

treatment  of,  i.  130 
Bursae,  fibula,  head.  i.  524 

-real  trochanter  of  femur,  i.  509 

inflammation,  i.  427 

ischial  tuberosity  (weaver),  i.  491 

olecranon,  i.  475 

prepatellar,  i.  523 

psoas,  i.  509 

sartorius,  i.  524 

semi-membranosus,  i.  524 

subdeltoid,  injuries  of,  i.  2(58 

subligamentous  (patellar),  i.  52(3 

tibial  tubercle,  i.  524 
Butlin,  excision  of  larynx,  ii.  481 


Caecum,  cancer  (operation),  ii.  225 

tuberculosis,  ii.  201 
Calcaneum,  fracture,  i.  345 
Calculus,  set  Biliary  passage,  bladder,  kidney, 

salivary  glands 
Calliper  splint  (Thomas'),  i.  314 
Calmette  s  tuberculin  reaction,  i.  190 
Cancer,  i.  82 

acute  (breast),  ii.  081,  (387 
antrum,  ii.  411 
bladder,  ii.  579 
bone,  ii.  387 
branchial,  ii.  485 
breast,  ii.  (379  693 
columnar  celled,  i.  86 
intestine,  ii.  220-230 
kidney,  ii.  551    555 
larynx,  ii.  473 
lip,  ii.  375 
liver,  ii.  171 
nasal  cavities,  ii.  387 
oesophagus,  ii.  481 
ovary,  ii.  344 
pancreas,  ii.  192 
penis,  ii.  033 
pharj  n.\,  ii.  450 
prostate,  ii.  602 
rodent  ulcer,  i.  85 


Cancer,  sebaceous,  i.  562 
spheroidal  celled,  i. 
squamous-celled,  i.  S3 

stomach,  ii.  251 

testis,  ii.  659 

thyroid,  ii.  493 

tongue,  ii, 

tonsil,  ii.  450 

uterus,  ii.  351 

varietic  s,  i.  83 
Cancrum  oris.  i.  178 
Carbolic  acid.  i.  145 
Carbuncle,  i.  166 
Carcinoma,"'  Cancer 
Carcinomatosis  peritonei,  ii.  12(> 
Cardiospasm,  ii.  459 
Caries,  i.  348 

S  •  also  Bone,  diseases  "t 
Carnochan,  operation  on  supraorbital  nerve, 

i.  (373 
Carotid  artery,  aneurysm,  ii.  35 
ligature,  ii.  52.  55 

body,  tumours  of.  ii.  485 
Carpus,  injuries,  i.  297,  298 

tuberculosis,  i.  47s 
Carr,  splint  for  fractures  at  wrist,  i.  296 
Carrel,  suture  of  arteries,  ii.  47 
"  Carrying-angle  "  of  elbow,  i.  283 
Caseation,  i.  44 
Catgut,  preparation  of,  i.  149 

Catheter   •fever.''  ii.  539,  619 

•■lite.'"  ii.  598 
Cauda  equina,  affec  ions  of,  i.  094 
Causalgia  (nerves),  i.  680 
Cavernous  sinus,  thrombosis,  i.  024 
Cellulitis,  i.  168 

neck.  ii.  480 

S      Ludfl  ig  -   mgina 

of  special  regions,  i.  109 

orbit,  ii.  : 

pelvic,  ii.  342 

relation  to  Lymphangitis,  ii.  74 

scrotum,  ii.  626-665 
Cephal-haematoccele,  i.  563 
Cephal-hydroccele  (traumatic),  i.  568 
Cerebellar  abscess,  i.  628 

tumours,  operation,  i.  037 
Cerebellum,  lesions  of.  i.  584 
Cerebral  abs  osis,  i.  629 

>      Brain 
non-otitic,  i.  r>2s 
temporo-sphenoidal, 
treatment,  i.  030 

•"  irritation,"  i.  589 
I  train 

tumours,  i.  035 

operations  for,  i.  637 
Cerebro- cranial  topography,  i.  57.) 
Cerumen  (in  ear),  i.  60 . 
Cervical  fascia,  ii.  482 

plexus  (injuries),  i.  681 

ribs.  i.  450 
Champoniere,  Lucas,  massage  for  Era 

i.  228 
Chancre,  diagnosis  of,  i.  201 

hard.  i.  199 

Hunterian,  i.  199 

soft,  i.  173 

varieties  of,  i.  200 
Chancroid,  i.  173 
Charcot,  neuropathic  joints,  i.  410 


[NDEX 


Chauffeurs  fracture,  ii.  296 
Cheek,  leucoplakia, ii.  4 lit 

a<  «  grow  ths,  ii.  4  L9 
Cheyne-Stokes  respiration,  i 
Chiene.  cerebro-cranial  topography,  i.  580 
Chilblain,  i.  131 

Chinuiey-sweep  s  cancer,  ii.  664 
Chlorolonn,  i.  137.     Se<  Anaesthesia 

Losis 
Cholangitis,  ii.  180 
Cholecystectomy,  ii.  183 
Cholecystenterostomy,  ii.  1S4 
Cholecystitis,  ii.  179 
Cholecystotomy,  i 
Choledochenterostomy,  ii.  1*4 
Choledochostomy,  ii.  L82 
Choledochotomy,  ii.  183 
Cholelithiasis,  ii.  17-4 

Si  i  i  !all-8l 
Cholesteatoma,  i.  611,  013 
Chondro-arthritis  (Virchow),  i.  411 
Chondroma,  i.  95 

ie,  i.  380 
Chopart,  amputation  (mid-tarsal),  i.  .">.")."> 
Chordee,  ii.  613 
Chordoma,  i.  92 
Choi'io-epithehoma,  i.  99 
Circumcision,  ii.  ♦"»:;<  ► 
Circumflex  nerve,  i.  GS7 
Cirsoid  aneurysm,  i.  502.     See  Aneurysm 
Clappotage,  ii.  140 
Clavicle,  excision  of.  i.  401 

fractures  of,  i.  258-262,  265 
treatment,  i.  260-262 

osteomyelitis,  i.  400 

syphilis,  i.  40U 

tumours  of  i.,  400 
Claw  hand  (complete),  i.  686 
ulnar,  i.  G'JU 

Cleft-palate,  ii.  357 

after-treatment,  ii.  365 

itions  for,  ii.  359,  361    365 
Cloacae,  i.  369 
Cloudy  swelling,  i.  4:; 
Club  foot,  i.  5;i5-.j5U.     Set  Talipes 

traumatic,  i.  545 
Cocain,  i.  140 
Coccygeal  tumours,  i.  044 
Coccygodynia,  i.  :;"•"• 
Coccyx,  fractures,  i.  305 
Cock,  perinea]  section,  ii.  625 
Cold  abscess,  treatment  of,  i.  191 
Coley  S  fluid  for  tumours,  i.  L05 
Colic,  biliary,  ii.  170 

renal,  ii.  522 

varieties  of.  ii.  114 
Colitis,  ii.  202 

Collapse,  i.  114-110.     See  Shock 
Collargol,  urinary  diagnosis',  ii.  520 
Colles's  fascia,  ii'.  000,  626 
ire,  i.  295 

law,  . 
Colley,  cleft-palate  operation,  ii.  .'{01 
Colon,  cancer  of,  ii.  22 

tions  for,  ii.  225,  226 

idiopathic  dilatation,  ii.  260,  320 

lymphatics  of,  ii.  225 

_.   .  220 
Colostomy,  ii.  223,  265 

noma  of  the  rectum,  ii.  227,  228 
Coma,  diagnosis  of,  i.  591.     See  Brain 


Complement,  deviation  of,  i.  17.  159 
Complicated  frart  u iv-.  -      Fractures 
Compound  fractures.  -"   Fractures 
Condylomas,  i.  81,  203 
Congenital  detect-,  i.  :; 

Special  organs  and  regions 
Corneal  stumps,  i.  429 
Connell,  suture  of  intestine,  ii.  99,    <   I 
Conradi,  treatment  of  aneurysm,  ii.  31 
Constipation,  "absolute,"  ii.  234 
"'  Contre-coup  "  (brain),  i.  595, 
Coracoid  process,  fractures  of,  i.  267 
Coryza,  ii.  384 

Courvoisier's     law     (enlargement     of     gall- 
bladder with  jaundice),  ii  17s.  189 
Cowper,  gland-  of,  inflammation,  ii.  id 4 
Coxa  valga,  i.  507 

vara,  i.  507 
Coxitis,  i.  499,  etc.     See  Hip,  diseases  oi 
Cranio-tabes,  i.  354 
Cranium,  anatomy,  i.  504 

congenital  defects,  i.  505 
tiee  Menmgocoeles 

fractures  of  base,  diagnosis,  i.  572,  573 
of  vault,  i.  507-571 

frontal  base,  tumours  of,  i.  369 

hyperostosis,  i.  575 

operation  for  depressed  fracture,  i.  570 

pyogenic  infections,  i.  575 

syphilis,  i.  570 

tuberculosis,  i.  570 

tumours  of,  i.  577 
Crepitus,  fractures,  i.  220 
Cretinism,  bones,  i.  300 
Crile  on  shock,  i.  115 

excision  of  larynx,  ii.  4Sf 
Cripps,  cancer  of  rectum,  ii.  229 
Croft,     plaster-splint    for    fractured     tibia, 

i.  334 
Croup,  ii.  407 

Crucial  ligaments  (knee),  rupture,  i.  332 
Crutches,  i.  088 
Crutch-palsy,  i.  251 
Cubitus  valgus,  i.  283,  471 

varus,  i.  283,  471 
Cushing,   excision    of    Gasserian    ganglion, 

i.  075 
Cut  throat,  ii.  483 
Cystic  hygroma,  ii.  77 
Cystitis,  acute,  ii.  573-574 

chronic,  ii.  573-575 
Cystoscope,  renal  calculi,  ii.  52 1 

uses  of,  ii.  503,  504 
Cystotomy,  see  Bladder  operations 
Cysts,  arachnoid,  i.  595 

Baker's,  i.  399 

branchial,  ii.  360 

broad  ligament,  ii.  348 

degenerative,  i.   108 

dental,  ii.  403,  409 

dentigerous,  ii.  408 

dermoid,  i.  108 

embryonic,  i.  107 

hydatid,  i.  217 

implantation,  i.  108 

inflammatory,  i.  Iu7 

kidney,  ii.  551,  553,  556 
Eydro-nephrosis 

mesenteric,  ii.  129 

neck,  ii.  485 

ovarian,  ii.  340-348 


INDEX 


Cysts,  pancreas,  ii.  190 
parasitic,  i.  108 
retention,  i.  108 
sebaceous,  i.  109 
thyroglossal,  i.  507 
umbilical  (urachal  or  allantoic,  vitelline), 

ii.  271 
urachal,  ii.  559 


Dactylitis  (tuberculous),  i.  486 
"  Dangerous  area,"  scalp,  i.  500 
Deformity  in  fractures,  i.  220 

ial  regions 
Degenerations,  i.  5 

amyloid,  i.  4:; 

calcareous,  i.  44 

causes  of,  i  42 

colloid,  i.  44 

fatty,  i.  43 

glycogenic,  i.  44 
tular,  i.  43 

hydropic,  i.  43 

nerves,  i.  050.  658 

pigmentary,  i.  44 

varieties  of,  i.  43 
Delhi  boil,  i.  196 
Delirium,  i.  112 

treatment  of,  i.  113 

tremens,  i.  112 

Deltoid  bursa,  i.  405 
Dental  caries,  ii.  403 
it,  ii.  403 

ulcer,  ii.  423 

Dentigerous  cyst,  ii.  4ns 
Dermoids,  i.  422  ;  ii.  270,  307 

ovarian,  i.  77  ;  ii.  345 

sequestration,  i.  107 

tubulo-,  i.  107 
Deviation  of  complement,  i.  157 
De  Vilbiss,  punch-forceps  (skull),  i.  586 
Diabetes,  relative  to  surgery,  i.  118 
Diaphragm,  hernia  through,  ii.  305 
Diaphysectomy  (osteomyelitis),  i.  369 
Diaphysitis,  diagnosis,  i.  368 

acute,  i.  303 

fulminating,  i. 

treatment,  i. 
Dietl,  crises  in  movable  kidney,  ii.  51s 
Diphtheria,  i.  179 

nasal,  ii.  384 

pharynx,  ii.  440 
Dislocation,  acromioclavicular,  i.  205 

ankle,  i.  340,  344 
astragalus,  ii.  :i  14 
carpal  bones,  L  298 
congenital  of  hip,  i.  493   198 
elbow,  i.  287 
Bngers,  i.  300,  301 
hip,  i.  307 
knee.  i.  :;2'.i 

metacarpophalangeal,  i.  299,  300 
old-standing,  i.  252 
radio-carpal,  i.  2'.i7 
radio-ulnar  (lower),  i.  2'.i7 
radius  (head),  i.  259 
reduction  of,  i.  251 
shoulder-joint,  i.  268  273 

old-standing,  i.  27:; 

recurrent,  i.  274 
sterno-clavicular,  i.  - 


Dislocation,  sub-astragaloid,  i.  344 

tendons,  i.  255 
ulna,  i.  288,  290 
unreduced,  i.  250 

varieties  of.  i.  249 

wrist,  i.  297 
Diver ticulitis,  ii.  218 
Drainage,  abdomen,  ii.  95 

wounds,  i.  124 
Dressings,  preparation  of,  i.  15 j 
"  Drill  bone."  i.  330 
Dugas  S  test,  shoulder  injuries,  i.  204 
Dunhill,  exophthalmic  goitre,  ii.  496 
Duodenal  ulcer,  ii.  136 

haemorrhage  from,  ii.  142 

]i  srforation  of,  ii.  139-142 

signs,  ii.  147 

treatment  of,  ii.  147,  148 
Dupuytren  S  contracture  (finger),  i.  482 

fracture,  i.  341 
Dura  mater,  infections  of,  i.  620,  621 

See  Meninges 
Dwarfism,  i.  350 
Dysentery,  amoebic,  i.  190 

joints  affected  by,  i.  402 

ulcers  of,  ii.  202 
Dysmenorrhcea  from  fibroids,  ii.  349 
Dyspepsia,  ii.  129 

gall-stone,  ii.  175 


Ear,  anatomy,  i.  (301 

artificial  drum.  i.  612 

caries  of  temporal  bone,  i.  015 

cholesteatoma,  i.  (311.  013 

cranial  relations,  i.  003 

epithelioma,  i.  007 

Eustachian  catarrh,  i.  009 

examination,  i.  003 

exostosis,  i.  607 

external,  affections,  i.  GOG 

mastoiditis,  i.  014 

meatus,  boils,  i.  607 
cerumen,  i.  007 
eczema,  i.  007 
foreign  bodies,  i.  GOG 

middle,  inflammation,  i.  608 
injuries,  i.  608 
operations  on,  i.  010   620 
.Mastoid 

otitis  media,  acute,  i.  009. 
chronic  suppuration,  i.  011 
Set  Otitis  media 

oto-sclerosis,  i.  612 

polypi,  i.  613 
Ecchymosis,  i.  122 
Echinococcus,  i.  217.     8e*  Hydatids 
Ecthyma,  L  203 
Ectopia  vesica,  ii.  559.  560 
Ectopic  gestation,  ii.  338 
Edwards,  cancer  of  rectum,  ii.  229 
Effleurage  mi— agi  .  i.  238 
Ehrlich,  salvarsan,  i.  212 
Elbow,  acute  inflammations,  i.  472 

anatomy  of,  i.  282 

ankylosis,  i.  474 

"  carrying-angle,"  i.  283,  471 

congenita]  defects,  i.  471 

dislocations  of,  i.  287,  289,  290 

flail,  i.  475 

operations  on,  i.  473,  475 


10 


INDEX 


ElbOW,  "■  pulled.''  i.  .' 

tuberculosis,  i.  it:; 
Electrical  discharges,  injuries  from,  1.  132 
Elephantiasis,  Li. 

..  mphatic  obstruotion 

penis,  ii.  633 

Emboli,  air.  ii.  15,  20,  -1 

clot,  ii.  15,  21 

fat.  ii.  Id 

infective,  ii.  L5 

parasitic,  ii.  1.") 

simple,  ii.  15 

varieties  of,  ii.  14.  15 
Emphysema,  surgical,  ii.  7o2 
Empyema,  ii.  705  708 

chronic  (Schede's  and  Estlander's  opera- 
tions), ii.  7o7 
Encephahtis,  i.  626 
Encephalocoele,  i.  565 
Endothelioma,  i.  89 
Enterectomy,  ii.  265 

intestine,  resection 
Enteritis,  after  laparotomy,  ii.  :;i  1 

diagnosis  from  peritonitis,  ii.  114 
Enteroanastomosis,  ii.  ion.  280 
Enterocoele,  ii.  276 
Enteroliths,  ii.  198 
Enterostomy,  ii.  266 
Enter otomy,  ii.  - 
Eosinophilia,  i.  120 
Epicritic,  Bensation,  i.  654 
Epididymis,  ii.  652  656.     Set  Testis 
Epididymitis,  acute,  ii.  652 

chronic,  ii.  653 

syphilitic,  ii.  656 

tuberculous,  ii.  654 
Epiglottis,  a  i  Larynx 
Epilepsy,  JackMiniau (cerebral tumours), i.  635 

operative  treatment,  i.  633 
Epiphyses,  separation  of,  i.  222 

Iso  individual  bones 
Epiphysitis  (acute),  i.  304 

syphilitic,  i.  37(5 

tuberculous,  i.  371 
Epiplocoele,  ii.  276 

Epiplopexy  (Talma,  Morrison),  ii.  127 
Epistaxis,  ii.  333 
Epithelioma,  i  ^'>.     -s"  Cancer 
Epulis,  fibrous  (pink),  ii.  409 

myeloid  (purple),  ii.  4K> 
Erb,  upper-arm  paralysis,  L  684 
Ergot,  gangrene  from,  i.  « "» 4 
Erichsen,  "  railway  spine,"  i.  634 
Erysipelas,  i.  168 

Estlander,  empyema  (operation),  ii.  707 
Ether,  i.  137.     S<  •  Anaesthesia 
Ethmoid,  affections  of,  ii.  393,  3 
Ethyl  chloride,  i.  138.     fita  Anaesthesia 
Eustachian  catarrh,  i.  608 

catheter,  i.  604 

tube,  i.  004 
Excision,  ankle  (Kocher),  i.  533 

elbow,  i.  473,  47.3 
hip.  i.  510 
jaw.  ii.  413   416 
joint-,  i.  4  I '.i 

for  tubercle,  i.  4(1'. I,  410 
knee.  i.  525 
shoulder,  i.  466 
wri.^t,  i.  478 


Exomphalos,  ii.  298 
Exophthalmic  i^oitiv.  ii.  194 
Exophthalmos,  pulsating,  ii.  22 

>■  i  Aneurj  sm,  retro-orbital 
Exostosis,  i.  3 7'. i 

subungual,  i.  379,  538 
Extension  for  fractures,  i.  313.  314 
Eye,  excision  of  globe,  ii.  369 

new  grow  ths,  i.  369 


Face,  new  growths,  ii.  372 
Facial  artery,  ii.  55 

cleft  (oblique),  ii.  357 

nerve,  i.  ii77 
Facies,  Hippocratic,  ii.  113 
Faeces,  impacted,  ii.  260 
Fallopian  tul  Li,  338  3  12 

Farcy,  i.  173.     Set  Glanders 
Fat,  embolism,  i.  228 

necrosis,  ii.  186 
Femoral  aneurysm,  ii.  38 

artery  i  Ligature),  ii.  63  -65 

hernia,  ii.  2!>4 
Femur,  deformities,  i.  " > <  > T  509 

diaphysitis,  i.  ■">!:; 

fractures,  i.  311    321 

tumours,  i.  513 

Fever,  i.  Ill 
Fibroma,  hard.  i.  93 

soft.  i.  93 
Fibromatosis,  i.  '»4 
Fibula,  diaphysitis,  i.  529 

fractures,  i'.  335.  339 
Fifth  nerve  (trigeminal),  i.  670  <'>77 
Filaria   sanguinis    hominis   (lymphatic    ob- 
struction), ii.  75.     Set   Elephantiasis 
Filigree  (silver)  tor  hernia-,  ii.  293,  302-304 
Fingers,  amputation,  i.  4>7 

deformil  Les,  i.  479,  480 
(fascial),  Dupuytren,  i.  4s2 

dislocation,  i.  300  -301 

fracture,  i.  300 

infections  (acute),  i.  483.     «S'e<  Whitlow 

new  growl  !i~.  i.  487 

tendons,  deformities  from.  i.  480 

■•  trigger,"  i.  4!Sl 

tuberculosis .  i.  186 

■•  webbed."  i.  480 

Finney  s  operation  (pylorus),  ii.  1Gb 
Fistulse,  i.  4ii 
aerial,  ii.  484 

biliary,  ii.  272 
bladder,  ii.  583 
branchial,  ii.  366 
faecal,  ii.  272 

I  Lc,  ii.  272 
'■  horse  shoe  "  rectal,  ii.  332 
in  ano.  ii.  331 

;!  ment,  ii.  :;:;  l 

intestinal,  ii.  273 
penile,  ii.  627 
perineal,  ii.  627 
recto-vesical,  ii.  584 
renal,  ii.  546 
salivary,  ii.  43  1 
scrotal,  ii.  r>27.  663 
thyroglossal,  ii.  367 
umbilical,  ii.  272 
urachal,  ii.  559 
\  esical,  ii.  584 


INDEX 


11 


Fits,  Jacksonian,  i.  584 
Flat-foot,  i.  456 

after  fractures  at  the  ankle,  i.  342 
Flat-foot,  gonorrh teal,  i.  459 

traumatic,  i.  548 
Foetal  inclusions,  i.  77 
Foot,  claw,  i.  545 

deformities,  i.  538-549.     See  Club  foot 

diseases,  i.  537-557 

flat-,  i.  450 

hollow,  i.  545 
Foot-in-axilla,       reduction      of      dislocated 

shoulder,  i.  272 
Forearm,  amputations,  i.  477 

deformities,  i.  470 
Foreign  bodies  in  tissues,  i.  128 

Nee  individual  organs 
Formalin,  i.  146 
Forster,    division    of    posterior    roots    for 

Spastic  paralysis,  i.  554 
Fowler  s  position,  peritonitis,  ii.  97 
Fractures,  acromion,  i.  205 

aetiology,  i.  220 

after-treatment  of,  i.  238 

amputation  for,  i.  240 

astragalus,  i.  346 

carpal  hones,  i.  297 

chauffeur's,  i.  2!t(i 

clavicle,  i.  258-262,  265 

coccyx,  i.  305 

('olio's,  i.  295 

complications,  i.  238-247 

compound,  i.  239 

crutch-palsy,  i.  247 

diagnosis  of,  i.  225 

dislocations  complicating,  i.  241 

Dupuytren's,  i.  340 

externa]  and  internal  splinting,  i.  237 

femur,  i.  312,  323 

fibula,  i.  334-342 

first-aid,  L  228 

fixation,  i.  229 
grene  m.  i.  243 

humerus,  i.  274  286 

ischsemic  contracture  in,  i.  243 

into  joints,  i.  241 

massage  for,  i.  237 

metacarpals,  i.  298,  299 

metatarsals,  i.  34tj 

myositis  ossificans,  i.  240 

nail  extension,  i.  237 

nerves  injured  in,  i.  2  42 

non-union  of,  i.  243 

obstacles  to  reduction  of,  i.  234 

olecranon,  ii.  291 

operative  treatment  of,  i.  231 
id  is,  i.  345 

pelvis,  i.  302-305 

phal  ger),  i.  30U 

plaster  of  Paris  for,  i.  230 

plating,  i.  237 

pneumonia  in,  i.  217 

poroplastic  splints,  i.  231 

Pott's,  i.  339 

pseudoarthrosis,  i.  243 

radius,  lower  end,  i.  295  -296 
shaft,  ii.  292,  293 

repair  of,  i.  223 

results  of,  general,  i.  228 

sacrum,  i.  305 

sarcoma  in,  i.  247 


Fractures,  scapula,  i.  205 
screwing,  i.  236 

••  setting.  "  i.  229 

skull,  i.  5011-573.     See  Cranium 

splints,  i.  230 

tibia,  i.  334-337,  339-342 

ulna,  shaft,  i.  292,  293 
styloid,  ii.  296 
ujmer  end,  ii.  291 

varieties  of,  i.  221 

vessels  injured  in,  i.  242 

vicious  union,  i.  245 

weight-extension,  i.  229 

wiring,  i.  236 
Fragilitas  ossium,  i.  221,  351 
Framboesia,  i.  216 
Frank,  gastrostomy,  ii.  158 
Frontal  sinus  (affections  of),  ii.  392 
Frost-bite,  i.  131 
Furuncle,  i.  164 


Gall-bladder,  ii.  172.    Set  Biliary  passages 
cancer,  ii.  178 
drainage  of.  i.  179,  181 
empyema,  ii.  177 
excision  of,  ii.  183 
mueocoele,  ii.  177 
tumours,  ii.  180 
ulceration,  ii.  178 
Gallows  splint,  i.  320 
Gall-stones,  ii.  174 
aetiology,  ii.  174 

intestinal  obstruction  by,  ii.  247 
obstruction,  treatment,  ii.  257 
results  of,  ii.  170,  177 
signs  of,  ii.  176 
treatment  of,  ii.  17s 
varieties,  ii.  174,  175 
Ganglia,  i.  424 
Gangrene,  diabetic,  i.  03 
dry,  i.  58 
embolic,  i.  04 
endarteritic,  i.  02 
ergot,  i.  64 
in  fractures,  i.  243 
gas,  i.  65,  178 
infective,  i.  05 
intestine,  ii.  253 
lung,  ii.  709 
moist,  i.  59 
post-febrile,  i.  03 
Raynaud's  disease,  i.  64 
senile,  i.  62 
signs  of,  i.  59 
traumatic,  direct,  i.  01 

vascular,  i.  61 
treatment  of,  i.  00 
general,  i.  60 
Gasserian  ganglion,  excision,  i.  675,  070 
Gastrectomy  for  cancer,  ii.  156 
Gastric  fistula,  ii.  272 
ulcer,  ii.  130 
excision  of,  ii.  144 
gastroenterostomy  for.  ii.  144 
haemorrhage  from,  ii.  142 
medical  treatment  and  results,  ii.   139. 

143 
perforation  of,  ii.  139-142 
stenosis  from,  ii.  144 
Gastritis,  phlegmonous,  ii.  136 


12 


INDEX 


Gastro-gastrostomy,  ii.   147 
Gastrojejunostomy,  ii.  160 

anterior,  ii.  165 
retro-colic,  ii.  165 

complications,  ii.  10;") 

duodenal  ulcer,  ii.  148 
no  ulcer,  ii.  14-4 

in  hour-glass  stomach,  ii.  147 

indications  for,  ii.  161 

isoperistaltic,  ii.  164 

no-loop  (Mayo),  ii.  162 

stoma,  position  of,  ii.  I  til 

"  vicious  circle,"  ii.  166 
Gastroplasty,  ii.  146 
Gastroplication,  ii.  160 
Gastrorrhaphy,  ii.  160 
Gastro-staxis,  ii.  143 
Gastrostomy,  ii.  157 

cancer  of  oesophagus,  ii.  461 
Gastrotomy,  ii.  135,  157 
Gelenk-maus,  i.  398 
Genu  recurvatum,  i.  520 

valgum,  i.  521-522 
osteotomy,  i.  527 

varum,  i.  522 
Gigantism,  L  350 
Gingivitis,  ii.  405 
Glanders,  i.  173 
Glands,   lymphatic,   ii.    70-86.     See  Lymph 

nodes 
Gleet,  ii.  611,  613 
Glioma,  i.  92 
Globus  hystericus,  ii.  459 
Glossitis,  acute  parenchymatous,  ii.  421 

interstitial,  ii.  425 

superficial  (chronic),  ii.  422 
Glossopharyngeal  nerve,  i.  680 
•'  Glossy  skin,"  i.  660 
Glottis,  oedema  of,  ii.  467 
Gluck,  excision  of  larynx,  ii.  480 
Gluteal  abscess,  i.  491 

aneurysm,  i.  491 ;  ii.  37 

bursitis,  i.  491 
Glycosuria,!.  118;  ii.  490 

See  Diabetes 
Goitre,  ii.  488-494.     See  Thyroid  gland 

exophthalmic,  ii.  494-497 
Gonococcal  peritonitis,  ii.  118 
Gonorrhoea,  i.  172 ;  ii.  611 

complications,  ii.  613,  614 

treatment,  ii.  612,  613 
Gonorrhoeal  joints,  L  402 
Gouty  joints,  i.  404 
Granulation  tissue,  i.  21 
Graves's  disease,  ii.  494 
Grawitz  tumours,  i.  88 

(kidney),  ii.  551 

Greenstick  "  fracture,  i.  222 
Grey  oil  (syphilis),  i.  214 
Gritti,  amputation  of  the  knee,  i.  529 
Groin,  abscess,  ii.  770 
Groves,  Hey  (fracture  of  patella),  i.  328 
Gummata,  L  205 

See  also  special  regions  and  organs 
Gums,  polypus,  ii.  406 

pyorrhoea  (Rigg),  ii.  405 
Gunshot   wounds   of   abdomen,   i.    128:    ii. 
107 

of  bone,  i.  127 

of  skull,  i.  127 
Gynaecology  (surgical),  ii.  337 


Heematemesis,  ii.  2.  132 
Heeniatoccele,  i.  122 

cephal-.  i.  .""ili.'! 

pelvic,  ii.  339 

spermatic  cord,  ii.  641 
Hsernatocoele,  vagina]  (testis),  ii.  640 
Hsematoma  amis,  i.  gug 

scalp,  i.  509 
Hsematomyelia,  i.  648 
Heemato-rhachis,  i.  648 
Hseniaturia,  ii.  2,  502,  5(14.  512,  523,  540,  543 

s  ..  Kidney 
Haemophilia,  ii.  16 

joints  in,  i.  417 
Haemoptysis,  ii.  2,  202 
Haemorrhage,  ii.  1 

acute,  ii.  4 

arrest  of  (natural),  ii.  5 

arterial,  ii.  2 

capillary,  ii.  3 

chronic,  ii.  4 

concealed,  ii.  4 

diagnosis  of,  ii.  4 

duodenal  ulcer,  ii.  142 

extradural,  i.  592 

first-aid  in,  ii.  6 

gastric  ulcer,  ii.  142 

infusion  of  saline  solution  in,  ii.  10 

internal,  ii.  4 

(abdominal),  ii.  108 
(ectopic  gestation),  ii.  339 

intracranial,  i.  592 

intradural,  i.  594.  5'.I5 

middle  meningeal,  i.  593 

prevention  of  (in  operations),  ii.  5 

reactionary,  ii.  11 

secondary,  ii.  11 

signs  of,  ii.  4 

spinal,  i.  648 

treatment  of,  ii.  7.  8,  9 
constitutional  effects,  ii.  9 

varieties,  ii.  2 

venous,  ii.  2 
Haemorrhoids,  ii.  321 

external,  ii.  :>22 

internal,  ii.  '.'>'2:\ 

operations,  bleeding  after,  ii.  .'»2li 

treatment,  ii.  324,  325 
Hsemothorax,  ii.  702 
Hair-bails,  ii.  135 
Hallux  nexus,  i.  550 

rigidus,  i.  550 

valgus,  i.  550 

varus,  i.  550 
Halstead,  hernia  operation,  ii.  2'.)2,  293 

mammary  cancer,  ii.  687 

subcuticular  suture,  i.  152 
Hamilton  S   test  for  injuries   of  shoulder,  i. 

264 
Hammer  toe,  i.  552 
Hamstrings,     tenotomy     and     lengthening, 

i.  528 
Hand,  movement   of   interosseous  w 

i.  689,  692 
Handley,  cancer  of  breast,  ii.  604 

lymphangeioplasty,  ii.  77 
Hare-lip  (lateral),  ii.  358 

median,  ii.  :!57 

operations,  ii.  359,  360 
Hartley,  excision  of  Gasserian ganglion,  i.  675 
Hay  fever,  ii.  384 


INDEX 


13 


Head,  sensation  (varieties),  i.  654 

(types),  i.  640 
Healing  of  wounds,  i.  20 

tissues,  various,  i.  23 
Heart,  acute  compression,  ii.  60S 

massage,  ii.  701 
Heart,  wounds  of,  ii.  698,  699 
Heat  exhaustion,  i.  133 
Heel  (painful),  i.  550 
Henderson  on  shock,  i.  116 
Hepatic  abscess,  ii.  169 
fever  (Chacot),  ii.  ITT 
Hernia,  acquired  inguinal,  ii.  283 
aetiology,  ii.  2T4 
anatomy,  ii.  2T5 
bilocular,  ii.  282 
congenital  funicular,  ii.  281 

vaginal,  ii.  281 

varieties,  ii.  279,  280 
i  ontents,  ii.  276 
diaphragmatic,  ii.  305 
encysted,  ii.  2S1 
femoral,  anatomy,  ii.  295 

diagnosis,  ii.  296 

operations,  radical,  ii.  297 

strangulated  (operation),  ii.  315 

treatment,  ii.  296-297 
gluteal,  ii.  305 
incarcerated,  ii.  306 
incisional,  ii.  302 
inflamed,  ii.  307 
inguinal,  anatomy,  ii.  278 

diagnosis,  ii.  284,  285 

operations,  indications,  ii.  288 

radical  operations,  ii.  289-294 

signs  of,  ii.  283 

Emulated  (operation),  ii.  314 

treatment,  ii.  286-294 

trusses,  ii.  286 

varieties,  ii.  279 
internal,  ii.  237 

treatment,  ii.  252 
interstitial,  ii.  282 
irreducible,  ii.  306 
linca  alba,  ii.  ">n_' 
lumbar,  ii.  305 
obstructed,  ii.  306 
obturator,  ii.  304 

t reatment,  ii.  305 
paraduodenal,  ii.  2:17 
pelvic,  ii.  ::<).") 
aacless,  ii.  283 

treatment,  ii.  294 
sciatic,  ii.  305 

■  if.  ii.  277 
Bliding,  ii.  283 
si  rangulated,  ii.  308 

operations,  ii.  313 

taxis,  ii.  311 
taxis  (failure  of),  ii.  311 
umbilical,  adults,  ii.  300 

infantile,  ii.  299 
ration,  ii.  301 
undescended  testis  with.  ii.  282 

ventral,  ii.  300 

cerebri,  i.  63] 
Herniotomy,  ii.  312 

Hey,  amputation  (tarso-metatarsal),  i.  556 
Hibbs,  operation  for  spinal  caries,  i.  117 
Hip,  anatomy,  i.  305 

ankylosis,  i.  609 


Hip,  arthritis  (acute),  i.  499 

bursas  (diseases),  i.  509 

Charcot's  disease,  i.  506 

dislocation,  congenital,  i.  492,  498 
open  operation,  i.  499 
reduction  of,  i.  310 

dislocation  (traumatic),  i.  301 

excision  for  tuberculosis,  i.  206 

hysterical,  i.  417,  507 

operations  on,  i.  510 

rheumatoid  affection,  i.  506 

snapping,  i.  499 

tuberculosis,  i.  500-506 
(bilateral),  i.  504 
operations,  i.  506 
Hippocratic  fades,  ii.  113 
Hirschsprung's  disease  (colon),  ii.  260 
Hodgen  s  splint,  i.  318 
Hodgkin  s  disease,  ii.  84 
Horns,  cutaneous,  i.  80 
Hospital  sore  throat,  ii.  441.  442 
Hour-glass  stomach,  ii.  145 
Housemaids  knee.  i.  :>24 
Humerus,  amputation  through,  i.  471 

diaphysitis,  i.  470 

fractures  of,  condyles,  i.  284 
great  tuberosity,  i.  277 
lower  end,  i.  283,  286 
neck,  i.  274,  27.~> 
shaft,  i.  281 
supracondylar,  i.  283 

separation  of  lower  epiphysis,  i.  286 
upper  epiphysis,  i.  27<i 

tuberculosis,  i.  471 

tumours  of,  i.  471 
Hunger  pain,  ii.  130 
Himter,  treatment  of  aneurysm,  ii.  30 
Hunterian  chancre,  i.  199 
Hutchinson,  dislocation  of  thumb,  i.  300 

pill  (syphilis),  i.  214 

results  of  treatment  of  syphilis,  i.  21."> 

teeth,  i.  208.     See  Congenital  syphilis 

trigeminal  neuralgia,  i.  (i71 
Hydatids,  i.  216.     See  individual  organs 

bone,  i.  378 

liver,  ii.  171 
Hydrencephalocoele,  i.  565 
Hydrocephalus,  i.  638 
Hydroccele,  chylous,  ii.  76 

acute,  ii.  646 

bilocular.  ii.  04.") 

congenita],  ii.  645 

diffuse,  of  cord,  ii.  64'.> 

encysted  (of  cord),  ii.  64."> 

hernia]  sac.  ii.  646 

infantile,  ii.  64.~> 

of  neck.  ii.  78 

(scrotal),  ii.  642  649 

testis,  ii.  649 

vagina]  (common),  ii.  647 
treatment,  ii.  647,  648 
Hydronephrosis,  causes,  ii.  ~>:!4  .">:?."> 
Si  i  Kidney 

treatment,  ii.  537 
Hydrophobia,  i.  183 
Hydrops  articuli,  i.  392 
Hygroma,  cystic,  i.  90;  ii.  78 
Hylomas,  i.  70 
Hyoid  bone,  fracture,  ii.  4 * i * "» 
Hypernephroma,  ii.  551 
Hypertrophy,  i.  6 


14 


INDEX 


Hypoglossal  nerve,  i.  6SI 
Hypospadias,  ii.  C05 
Hysterectomy,  cancer,  ii.  352 

fibroids,  ii.  351 
Hysteria,  traumatic,  i.  634 
Hysterical  joints,  i.  417 


Deus,  adynamic,  ii.  231 

mechanical,  ii.  230  etc. 
See  Intestinal  obstruction 

paralytic,  ii.  231 

(in  strangulated  hernia),  ii.  311 
Hiac,  abscess,  i.  441 

aneurysm,  ii.  37 

arteries  (ligature),  ii.  62 
Immune-body,  i.  157 
Immunity,  active,  i.  17 

passive,  i.  17 
Incontinence  (urine)  in  spinal  cord  lesions, 

i.  642 
Indian  method  of  repairing  nose  (modifica- 
tion), ii.  380-381 
Indigo  carmine,  test  of  renal  adequacy,  ii. 

504,  505 
Infarcts,  ii.  15,  16 
Infections,  we  Bacteria 

anthrax,  i.  175 

B.  Mallei  (glanders),  i.  173 

colon  bacillus,  i.  171 

Ducrey's  bacillus,  i.  173 

gonorrhceal,  i.  172,  402  ;  ii.  611 

joints,  i.  400 

pneumococcal,  i.  171 

puerperal,  ii.  341 

(specific),  diagnosis  of,  i.  157 

staphylococcal,  i.  164 

streptococcal,  i.  167 
Inflammations,  i.  4,  19 

course  of,  i.  25 

diagnosis  of,  i.  30 

signs  of,  i.  28 

treatment  of,  i.  30 

variations  of,  i.  24 

varieties  of,  i.  26 
Influenza,  joints  affected  by,  i.  401 
Infusion,  saline  solution,  i.  116  ;   ii.  10 
Ingrowing  toe-nail,  i.  552 
Inguinal  aneurysm,  ii.  37 

hernia,  ii.  278.     See  Hernia 
Injuries,  i.  4,  122,  etc. 

arteries,  ii.  17 

and  veins  together,  ii.  21. 

See  also  Abdomen,  bladder,  fractures. 
kidney,  skull,  etc. 
Innominate  aneurysm,  ii.  35 

artery,  ii.  51 
Insanity,  after  head  injuries,  i.  634 
Instruments,     preparation     for     operation. 

i.  144 
Intercostal  arteries  (injury  of),  ii.  697 
Interilio-abdominal  amputation,  i.  490 
Inter-scapulo-thoracic  amputation  (Berger), 

i.  469 
Intestinal  adhesions,  ii.  110,  217,  239 
anastomosis,  ii.  99.     See  Anastomosis 
clamps,  ii.  97 
fistulas,  treatment,  ii.  27:', 
obstruction,  acute  on  chronic,  ii.  243 
acute,  diagnosis,  ii.  230 
pathology,  ii.  232 


Intestinal  obstruction,  acute,  signs  of.  ii.  233 
chronic,  signs,  ii.  259 
treatment,  ii.  261 
varieties,  ii.  259 

diagnosis,  ii.  249 
drainage  in,  ii.  252 
gall-stone,  ii.  247 
intussusception,  i.  241 
"  kinking,"  ii.  239 
laparotomy  in,  ii.  250 
mesenteric  thrombosis,  ii.  24S 
"  snaring,"  ii.  236 
treatment,  ii.  249 
varieties,  ii.  231 
volvulus,  ii.  239 
paralysis,  ii.  231.     See  Ileus  (adynamic) 
stasis,  ii.  263 
Intestine,  cancer,  excision,  ii.  224 
signs  of,  ii.  222 
spread,  ii.  221 
treatment,  ii.  223-230 

indications,  ii.  224,  225 
varieties,  ii.  220 
concretions,  ii.  199 
congenital  defects,  ii.  197 
diverticula,  ii.  196,  203 
foreign  bodies  in,  ii.  198 
gangrene,  ii.  253 

of,  in  hernia,  ii.  313 
inflammation  of,  ii.  199 
new  growths,  ii.  214 
operations  on,  ii.  265 
resection  of,  ii.  265 
cancer,  ii.  224-226 
for  gangrene,  ii.  253,  254 
rupture  of,  ii.  197 
snaring,  treatment,  ii.  202 
stenosis  of,  ii.  203 
surgical  aspects  of,  ii.  230 
suture  of,  ii.  97 
ulcers,  ii.  199 
wounds,  ii.  198 
Intoxication,  i.  5 
Intubation  of  larynx,  ii.  478 
Intussusception,  pedology,  ii.  242 
anatomy,  ii.  241 
chronic,  ii.  260 
resection  of,  ii.  257 
treatment,  ii.  256 
varieties  of,  ii.  244 
Involucrum,  i.  369 
Iodides  in  syphilis,  i.  214 
Iodoform,  i.  146 
Iritis,  syphilis,  i.  204 
Ischsemic  contracture,  i.  255 
Ischio-reetal  abscess,  ii.  331 
Ischium,  fracture,  i.  304 


Jackson,  epilepsy,  i.  584 

peritonea]  "  veils."  ii.  264 

Jacobson,  amputation  of  leg, 

Jaundice,  gall-stones,  ii.   17(1 

Jaw,  alveolar  abscess,  ii.  404 

ankylosis,  ii.  413 

operation,  ii.  416 
dental  cyst,  ii.  403,  409 
dentigerous  cyst.  ii.  408 
development,  ii.  354 
epulis,  ii.  409,  410 
fibrocystic  disease,  ii.  408 


')32 


INDEX 


15 


Jaw,  lower,  dislocation,  ii.  401 
fractures,  ii.  400,  401 
subluxation,  ii.  402 
:!iunt  tumours,  ii.  41 1 
myeloid  sarcoma,  ii.  410.  411 
necrosis,  ii.  407 
odontomas,  ii.  408 
operation  (excision),  ii.  413.  41G 
osteoma,  ii.  400 
periostitis,  ii.  408 
tumours,  ii.  407 
upper,  fracture,  ii.  399,  400 
Jejunal  ulcer,  ii.  167 
Jejunostomy,  ii.  108 

for  peril. rat  ii!  gastric  ulcer,  ii.  142 
Jejunum,  ulcers  of,  ii.  138 
"  Joint-mice,"  i.  333,  398 
Joints,    acromioclavicular,    injuries    of,    i. 

265 
ankle,  injuries,  i.  338 
ankylosis,  i.  395 
arthritis,  i.  391 
Charcot's,  i.  416*" 
contusion,  i.  247 

-  connected  with  (Baker),  i.  399 
dislocations  of,  i.  249 
dysenteric  affection,  i.  402 
elbow,  dislocation,  i.  287 
excision,  i.  397 
fractures  into,  i.  241 
functional  disorders  of,  i.  417 
gonorrhceal,  i.  402 
gout,  i.  4<»4 
haemophilia,  i.  417 
hip,  diseases,  i.  492,  etc. 

injuries,  i.  305,  etc. 
hydatids  of,  i.  418 
hysterical,  i.  417 
infections,  acute,  i.  4<iii 
influenza]  affection,  i.  40! 
injuries,  i.  329-333 
knee,  diseases,  i.  51  5 
loose  bodies  in.  i.  397 
neuropal  hi''  (<  lharcol ).  i.  41  (i 
new  growths  of,  i.  418 
operations  on.  i.  410 
pneumococcal,  i.  401 
puerperal,  i.  4i>2 
pyaemic,  i.  402 
pyogenic  infection,  i.  400 
rheumatism  (acute),  i.  402 
rheumatoid,  i.  412 
scarlatina]  affections  of.  i.  401 
shoulder,  anatomy,  i.  202 

diseases,  i.  463 

dislocation,  i.  20S-273 
sternoclavicular,  anatomy,  i.  257 

dislocations,  i.  258 
synovitis,  i.  390 
syphilis,  i.  4  1  1 
temporomandibular,   affect  ionsof.    i.     f!2. 

413 
tuberculous,  i.  405-  410 

treatment,  i.  408  410 
typhoid  infect  ion  of.  i.   10  1 
wounds  of.  i.  2  is 
Jones,  pes  cavus,  i  real  monl .  i.  545 
Jordan.  Furneaux,  amputation  at   the  hip, 

i.  512 
Juxta-epiphysial  infection,  i.  365 
s, ,   Diaphysitis 


Kader,  gastrostomy,  ii.  158 
Keegan,  repair  of  nose.  ii.  380 
Keloid,  i.  93 

Keratitis,  interstitial  (syphilitic),  i.  208 
Kidd,  abnormal  ureters,  ii.  511 
Kidney,  abscess  (circumscribed),  ii.  544 
(perinephric),  ii.  545 
acute  unilateral  infection,  ii.  539.  540 
anatomy,  ii.  508 
aneurysm  of  renal  artery,  ii.  515 
calculi,  ii.  519-534.     See  Renal  calculi 
cancer,  ii.  551,  555 
congenital  defects,  ii.  511 
cystic  (congenital),  ii.  551.  553 
cysts,  ii.  556 

examination  of,  ii.  508,  509 
exploration  of,  ii.  509-510 
fistula  of,  ii.  546 
function  of  (estimation),  ii.  505 
hydronephrosis,  ii.  534-537 
infections  of,  ii.  537-550 

See  Nephritis,  pyelitis,  pyonephrosis 
injuries  of.  ii.  512-515 
movable,  ii.  515,  519 

types  of,  ii.  517 
operations,  movable,  ii.  519 

nephrectomy  (acute  infective),  ii.  540 
(stone),  ii.  531 
(tubercle),  ii.  550 
nephrolithotomy,  ii.  530 
nephrotomy  (for  stone),  ii.  531 

(pyonephrosis),  ii.  544 
pyelotomy  (stone),  ii.  510,  530 
perinephritis,  ii.  545 
pyogenic  infections,  ii.  538-539 
pyonephrosis,  ii.  543-544 
syphilis,  ii.  550 
tuberculosis,  ii.  547,  550 
tumours,  ii.  550-555 
wounds,  ii.  514 

X-ray  examination,  ii.  526-528 
Killian,  laryngoscopy  (suspension),  ii.  453 
Klapp,  treatment  of  scoliosis,  i.  454 
Klumpke,  lower-arm  paralysis,  i.  685 
Knee,  amputations  about,  i.  52s 
arthrectomy.  i.  525 
arthrotomy,  i.  525 
aspiration,  i.  525 

bursas  (about),  i.  523-524.     See  Bursas 
<  'hareot's.  i.  519 
congenital  defects,  i.  515 
contracture,  i.  520 
deformities,  i.  520,  523 
excision,  i.  525 
"  flail."  i.  520 
hyperextension,  i.  520 

Si  e  <  tenu  recurvatum 
infections  (acute),  i-  515 
joint,  anatomy,  i.  321 
dislocation,  i.  329 
internal  derangements  of,  i.  331 
"  joint-mice,"  i.  .".:;:; 

loose  bodies  in.  i.  333 
knock,  i.  521.     See  ( lenu  valgum 
opera!  ions,  i.  525 
osteo-arthritis,  i.  519 
tuberculosis,  i.  515  51!) 
operations,  i.  51  s 
Koch,  "  postulates,"  i.  12 
Kocher,  ankle,  excision,  i.  533 
clamps,  intestinal,  ii.  97 


16 


INPKX 


Kocher,  dislocated  shoulder  (reduction),  i.  270 

excision  of  shoulder,  i.  467 

goitre,  exophthalmic,  ii.  496 
incision  for.  ii.  492 

hernia  operation,  ii.  290 

infra-orbital  nerve  (exposure),  i.  673 

knee  (excision),  i.  525 
Kbrte,  cysts  of  pancreas,  ii.  190 
Krause,  excision  of  Gasseiian  ganglion,  i.  675 
Kyphosis,  i.  438,  449 


Laminectomy,  i.  642.     See  Spinal  cord 
Lane,  cleft-palate  operation,  ii.  361 

fractures,  plating  of,  i.  236 

intestinal  stasis,  ii.  263 
Langenbeck  (cleft -palate),  ii.  361 
Laparotomy,  ii.  91 

See  Abdominal  operations 

intestinal  obstruction,  ii.  250 

paramedial,  ii.  92 
Lardaceous  disease,  i.  43 
Laryngitis,  ii.  466-470 

acute,  ii.  466 
Laryngoscope,  ii.  452 

(suspension),  Killian,  ii.  453 
Laryngotomy,  ii.  474 
Larynx,  anatomy,  ii.  404 

cancer,  ii.  472,  473 

diphtheria,  ii.  467 

excision  of  (cancer),  ii.  480,  481 

foreign  bodies,  ii.  464.  405 

infections,  ii.  466-47(1 

injuries,  ii.  467 

intubation  (O'Dwyer),  ii.  478 

cedema  of,  ii.  467 

papilloma,  ii.  470,  471 

paralysis,  i.  650  ;  ii.  473 

perichondritis,  ii.  470 

stenosis,  ii.  470 

syphilis,  ii.  468 

tuberculosis,  ii.  470 

wounds,  ii.  466-483 
Lateral  curvature  (spine),  i.  448 
See  Scoliosis 

sinus,  thrombosis,  i.  624 
operation  for,  i.  025 
Lavage,  stomach,  ii.  156 
Lead-poisoning,  ii.  114 
Leather-bottle  stomach,  ii.  151 
Leg,  amputation,  i.  531 

fractures  and  injuries,  i.  334-338 
Leishman-Donovan  bodies,  i.  196 
Lembert,  suture  of  intestine,  ii.  98 
Leontiasis  ossea,  i.  360  ;  ii.  410 
Lepidomas,  i.  70 

classification,  i.  79 

transitional,  i.  87 
Leprosy,  i.  194 
Leucocytosis,  i.  120 
Leukoplakia,  tongue,  ii.  422 

cheek,  ii.  419 
Leukaemia,  lymphatic,  i.  85 

spleno-medullary,  i.  95 
Ligatures,  ii.  49.     See  Arteries 

preparation  of,  i.  149 
Ligneous  phlegmon,  i.  167 
Linea  alba,  hernia,  ii.  302 
Lingual  artery,  ii.  55 

nerve,  i.  674 

thyroid,  ii.  426 


Lip,  cancer,  ii.  374,  375 

chancre,  ii.  374 

development,  ii.  354 

hare-,  ii.  357.     See  Hare-lip 

inflammation,  ii.  373 

macrocheilia,  ii.  373 
Lipoma,  ehcumscribed,  i.  94 

diffuse,  i.  94 

extra-peritoneal,  ii.  285,  302 

periosteal,  i.  3S0 
Lisfranc,  amputation   (tarso-metatarsal),   i. 

556 
Lister,  antisepsis,  i.  145 
Liston,  long  splint,  i.  314 
Litholapaxy  (stone  in  bladder),  ii.  507-570 
Lithotomy,  perineal,  ii.  571 

suprapubic,  ii.  570 
Lithotrite,  ii.  567 
Littre's  hernia,  ii.  308 
Liver,  abscess,  ii.  169 

cancer,  ii.  171 

hydatids,  ii.  171 

injuries  of,  ii.  168 

tropical  abscess,  ii.  160 
Lockwood,  femoral  hernia,  operation,  ii.  298 
Loose  bodies  in  joints,  i.  397,  398 
Lordosis,  i.  436,  449 

in  hip  disease,  i.  502 
Lorenz,  treatment  of  congenital  dislocation 

of  hip,  i.  495 
Loreta,     operation    for    congenital    pyloric 

stenosis,  ii.  151 
Lotheisen,  femoral  hernia  (operation),  ii.  297 
"  Lucid  interval."  intracranial  haemorrhage, 

i.  593 
Luetin,  i.  210 
Lumbar  abscess,  i.  441 

hernia,  ii.  305 

kidney  incision,  ii.  509 

puncture,  i.  585 
Lung,  abscess,  ii.  708 

gangrene,  ii.  709 

hernia,  ii.  703 

hydatids,  ii.  709 

injuries,  ii.  702 

phthisis,  ii.  708 

wounds,  ii.  703 
Lupus,  syphilitic,  i.  205 
Lymphadenitis,  acute,  ii.  78,  79 

chronic,  ii.  80 

ligneous,  ii.  80 

tuberculous,  ii.  81 

treatment  of.  ii.  82,  83 
Lymphadenoma,  ii.  84 
Lymphangioma,  ii.  77 
Lymphangeio-plasty,  ii.  77 
Lymphangiectasis,  ii.  75 
Lymphangitis,  acute,  ii.  74 

filarial,  ii.  75 

malignant,  ii.  75 

syphilitic,  ii.  75 

tuberculous,  ii.  75 
Lymphatic  glands,  ii.  71-86 
See  Lymph-nodes 

injuries  of,  ii.  73 

leukaemia,  ii.  85 

obstruction,  ii.  75 
Lymph-nodes,  distribution  of,  ii.  71,  72.  73 
See  Lymphadenitis 

tumours  of  (secondary),  ii.  S6 
Lymphoma,  i.  96 


INDEX 


17 


Lymphosarcoma,  ii.  85 
Lysol,  i.  14G 


McBumey,  muscle-splitting  incision  (laparo- 
tomy), ii.  93 

Macewen,  acupuncture  of  aneurysms,  ii.  30 
bone-grafting,  i.  389 
cerebral  abscess,  ii.  628 
hernia  operation,  ii.  291 

otomy  for  genu  valgum,  i.  527 

McGavin,  filigree  for  inguinal  hernia,  ii.  293 

Macintyre  splint,  i.  321,  336 

Mackenzie,     Hector,     exophthalmic     goitre, 
ii.  490 
kidney,  movable,  ii.  516 

Macrocheilia,  ii.  357 

Macroglossia,  ii.  42 1 

Macrostoma,  ii.  356 

Madelung,  deformity  of  wrist,  i.  477 

Madura  disease,  i.  194 

Main-en-griffe  (claw  hand),  i.  085,  089 

Majendie,  foramen  of,  i.  579 

Malarial  spleen,  i.  190  ;  ii.  194.  195 

Malcolm  on  shock,  i.  1 15 

Malgaigne,  dislocation  of  shoulder,  i.  209 

pharyngotomy,  ii.  479 
Malignant    disease,     see     Cancer.    Sarcoma, 

Tumours 
Mallet  finger,  i.  3ul 
Mandible,  see  Jaws 
Mandibular  cleft,  ii.  357 
Marwedel,  gastrostomy,  ii.  158 
Massage  for  fractures,  i.  238 
Mastitis,  acute  (varieties),  ii.  671 

chronic  interstitial,  ii.  073 
Mastoid,  affections  of,  i.  014-029 
See  Ear  and  Otitis  media 

radical  operation  (.Stiicke),  i.  017-020 
Mastoidectomy  (Stacke),  i.  017-020 
Mastoiditis,  acute,  i.  015 

chronic,  i.  616 

in  infants,  i.  618 

v.  Bezold's,  i.  615 
Matas'  treatment  of  aneurysm,  ii.  31 
Maxilla,  see  Jaws 

Maydl,  ectopia  vesicae  (operation),  ii.  560 
Mayo,  exophthalmic  goitre,  ii.  490 

gastrojejunostomy,  ii.  162 

hallux  valgus  (operation),  i.  o5o 

kidney  exploration,  ii.  510 

umbilical  hernia,  operation,  ii.  301 
Meckel's  diverticulum,  ii.  197 

affections  of,  ii.  219 
Median  nerve  (injuries),  i.  692 
Mediastinum,  infections,  ii.  710 
Melsena,  ii.  2,  132 
Melanoma,  i.  91 
Melanotic  carcinoma,  i.  91 

sarcoma,  i.  91 
Melon-seed  bodies,  i.  423 
Meningeal  haemorrhage,  i.  592-595 
Meningitis,  i.  620-024.     See  Brain 

(lepto),  acute,  i.  622.     See  Brain 

spinal,  i.  049 

tuberculous,  i.  621 
Meningoccele  (spinal),  i.  643 

(cranial),  i.  505 
Mental  states  in  brain  affections,  i.  582 
Mercury  biniodide,  i.  146 

oxycyanide,  i.  146 


Mercury  perchloride,  i.  146 

in  syphilis,  i.  214 
Mesenteric  glands,  ii.  129 

thrombosis,  ii.  129 
treatment,  ii.  207 
Mesentery,  cysts  of,  ii.  129 

glands  of,  affections  of,  ii.  129 

injuries  of,  ii.  129 

thrombosis  of  vessels,  ii.  129 
Mesothelioma,  renal,  i.  88 

Metacarpals,  fractures,  i.  299 

t  uberculosis,  i.  450 
Metatarsalgia,  i.  550 

Metatarsals,  fracture,  i.  340 
Metatarsus,  tuberculosis,  i.  538 
Michel's  clips,  i.  152,  153 
Mickulicz,  tarsectomy,  total,  i.  533 
Microcephaly,  i.  505 
Microstoma,  ii.  356 

Micturition,  disorders  of,  ii.  584-588 

frequency,  ii.  499,  523,  548 
Middledorp's  triangle  for  fractured  humerus. 

i.  2^2 
Middle-ear  disease,  see  Otitis  media 
Middle  meningeal  haemorrhage,  i.  593 
Miles,  cancer  of  rectum,  ii.  227,  229 
Miliary  tubercles,  i.  187 
Miller,  amputation  at  the  elbow,  i.  476 
Mollities  ossiurn,  i.  358.     See  Osteomalacia 

adolescent  type,  i.  350 
Moore,  treatment  of  aneurysm,  ii.  31 
Morbus  coxae,  i.  500 
Morris,  bitrochanteric  measurement  of  bin 

i.  306 
Morrison,  epiplopexy,  ii.  127 
Mortons  disease  (metatarsalgia),  i.  550 
Motor  area,  i.  581,  583 

See  Brain 
Mouth,  affections  of,  ii.  417-440 
Movable  kidney,  ii.  515-519 
Mucoccele,  ii.  309 
Mucous  patches,  i.  203 
Mumps,  ii.  436 
Murphy,  arthroplasty,  i.  397 

bone  grafting,  i.  390 

button  for  anastomising  gut,  ii.  105 

sign  of  gall-stones,  ii.  176 

suture  of  arteries,  ii.  46 
Muscles,  atrophy,  i.  420 

contracture,  ischaemic,  i.  255 

inflammation,  i.  421 

new  growths,  i.  422 

operations  on,  i.  425 

paralysis,  i.  420 

rupture  of,  i.  253 

spasm,  i.  420 
Musculo-spinal  nerve  (injuries),  i.  088 
Mycetoma,  i.  194 
My  co-bacteria,  i.  1S4 
Myelitis  (spinal  cord),  i.  049,  652 
Myeloccele  (spinal),  i.  043 
Myeloid  sarcoma  (myeloma),  i.  95,  382 

treatment,  i.  385 
Myeloma,  i.  95,  382 
Myelomatosis,  i.  90 
Myoma,  leiomyoma,  i.  96 

rhabdomyoma,  i.  96 
Myomectomy  (for  fibroids),  ii.  350 
Myositis  ossificans,  i.  240,  422 
elbow,  i.  292 

varieties,  i.  421,  422 


18 
Myxoma,  i.  9' 


INDEX 


Nsevus,  capillary',  i.  89 

or  cutaneous,  ii.  45 
cavernous,  i.  90  ;   ii.  45 
lymph,  ii  77 
Nails,  affections  of,  i.  4b3 
Nasal,  anatomy,  ii.  370 
bones,  fracture,  ii.  378 
cavities,  foreign  bodies,  ii.  3>d 

functional  disorders,  ii.  387 

infections,  ii.  383-384.     Sec  Khinitis 

rbinolitbs,  ii.  381 

tumours  of,  ii.  3S7 
diphtheria,  ii.  384 
examination,  ii.  377 
fossa?,  development,  i.  354 
hemorrhage  (epistaxis),  ii.  383 
polypi,  ii.  380 
septum,  deviations,  ii.  3b2 

spurs,  ii.  3b2 

ulceration,  ii.  383 
Epistaxis 
Nasopharynx,  ii.  394-398 

adenoids  of,  ii.  394,  395 
tumours  of,  ii.  397 
Navel,  set  Umbilicus 
Neck,  surgery  of,  ii.  482-485 
Necrosis,  i.  348.     Set  Bone,  diseases 
caseation,  i.  44 
coagulative,  i.  44 
colliquative,  i.  44 
fat,  i.  44  ;  ii.  186 
quiet  in  joints,  i.  405 
Negri,  intracellular  bodies  in  hvdrophobia, 

i.  183 
Nelaton,  measurement  of  hip,  i.  306 
Neoplasms,  see  Cancer,  Sarcoma,  Tumours 
Neosalvarsan,  i.  212 
Nephrectomy,  ii.  510 

See  Kidney  operations 
Nephritis,  acute  infective,  ii.  539,  540 

operative  treatment  of,  ii.  53b 
Nephropexy,  ii.  519 
Nephrotomy,  ii.  510 

See  Kidney  operations 
Nerves,  anastomosis,  i.  664 
auditors-,  i.  650 

brachial  plexus,  injuries,  i.  083-080 
bulbs  (amputation),  i.  661 
cauda  equina,  i.  694 
cervical  plexus,  i.  681 
sympathetic,  L  682 
circumflex,  i.  687 
division  (incomplete),  i.  660 

See  Causalgia 
examination  of,  i.  055 
external  cutaneous,  i.  095 

popliteal,  i.  090 
facial,  affections  of,  i.  077 

paralysis  in  otitis  media,  i.  612 
facio-hypoglossal  anastomosis,  i.  079 
glossopharyngeal,  i.  680 
gluteal,  i.  095 
grafting,  i.  664 
hypoglossal,  i.  681 
inferior  dental  (exposure  of),  i.  674 
inflammation,  i.  005 
infra-orbital,  exposure  of.  i.  673 
injuries,  clinical  results,  i.  65b,  00U 


Nerves,  injuries,  varieties,  i.  657 
intei  costal,  i.  094 
interna]  popliteal,  i.  697 

irritative  lesions,  treatment,  i.  664 
lingual,  exposure  of,  i.  074 

long  saphenous,  i.  095 
thoracic  (Bell),  i.  080 

lumbar  plexus,  i.  095 

median,  i.  692 

motor  functions,  i.  050 

museulo-cutancous,  i.  687 

musculo-spinal,  i.  08b 

neuralgia,  i.  007 

neuritis,  i.  005 

neuromas  (pseudo),  i.  001 

obtuiator,  i.  695 

oculomotor,  i.  070 

olfactory,  i.  069 

optic,  i.  669 

phrenic,  i.  Obi 

icaeticn  oi  degeneiation,  i.  05". 

recovery  of  function,  i.  002 

regeneration,  i.  002 

sacral  plexus,  i.  095 

scars  involving,  i.  001 

sciatic,  i.  095 

sensation  (varieties),  i.  054-655 

spinal  accessory,  i.  6bU 

supra-orbital,  exposure  of,  i.  073 

supra -scapular,  i.  0b  7 

suture,  primary  and  secondary,  i.  663 

trigeminal,  i.  071.     See.  Neuralgia 

tumours,  i.  008 

ulnar,  i.  689 

vagus,  i.  ObU 
Neuralgia,  i.  606-667 
See  Nerves 

ccivico-occipital,  i.  6bl 

epileptiform,  i.  07 li 

pleurodynia,  i.  094 

sciatica,  i.  697 

trigeminal,  i.  071 

operations  for,  i.  073-070 
Neuif  sthenia,  traumatic,  i.  03^ 
Neuritis,  i.  005.    See  Nerves 

oi. tie,  i.  009 
Neuic-fcfcrcrratosis,  i.  00b 
Neuicrra,  i.  92, 

(pseudo),  L  661 
Neurc-mirr.eE is,  joints,  i.  417 
Neurosis,  tiaumatic,  i.  633 

See  Bail-nay  spine 
New  growths,  i.  6.     See  Tumours 
Nicoll,  femora]  hernia  operation,  ii.  293 
Nipple,  chancre  of,  ii.  668 

cracks  of,  ii.  668 

eczema,  ii.  00b 

1  aget's,  ii.  00b-670 

retraction,  ii.  00b 
Nitrous  oxide,  i.  136. 

See  Anaesthesia 
Nocturnal  incontinence  of  urine,  ii.  o'ou 
Noguchi  on  syphilis,  i.  197,  210 
Ncma,  i.  17b 

Nose,  accessory  sinuses  of,  anatomy,  ii.  388 
examination,  ii.  3b9 

congenital  syphilis  of,  i.  376 

deformities,  i.  379 

injuries,  ii.  37b 

repair  of  (operation),  ii.  380,  381 

lhinoseopy,  ii.  377 


INDEX 


19 


Nose,  "  saddle  "  (syphilis),  ii.  379.    See  Nasal 
Novocain,  i.  141 


Obstruction,  intestinal,  ii.  230-2(35 
Se<  Ileus,  Intestinal  obstruction 

Obturator,  hernia,  ii.  304 

Occipital  artery,  ii.  55 

Odontomes,  i.  79 ;  ii.  408-409 
■s'>  i   Jaw 

0  Dwyer,  intubation  of  larynx,  ii.  478 

(Esophageal  bougie  (passage  of),  ii.  455 

QSsophagoscope,  ii.  453 

QSsophagotomy  (foreign  bodies),  ii.  458 
Oesophagus,  anatomy,  ii.  458 

corrosive  fluids,  swallowing,  ii.  457 

foreign  bodies,  ii.  457 

hysterical  spasm,  ii.  459 

in  juries,  ii.  456 

intrathoracic  surgery  of,  ii.'  709,  710 

pouches,  ii.  402,  405 

spasm,  ii.  459 

stricture  (cancer),  ii.  461-402 
(fibrous),  ii.  460 
Olecranon,  bursitis,  i.  475 

fracture,  i.  290 
Olfactory  nerve,  affections  of,  i.  668 
Omentum,  injuries  of,  ii.  128 

rolled,  ii.  128 

torsion  of,  ii.  128 
Onychia,  i.  483,  484 
Openshaw,  abduction  box-splint,  i.  316 
Operation,  after-treatment,  i.  153 

dressing  after,  i.  154 

incisions,  i.  151 

preparation  of  materials  for,  i.  149 
of  patient,  i.  147 
of  surgeon  for,  i.  147 

rooms  for,  i.  147 

suturing,  i.  151,  152 
Optic,  atrophy,  i.  669 

neuritis,  i.  669 
'"  Oral  sepsis,"  ii.  405 
Orbit,  aneurysm,  see  Exophthalmos,  pulsating 

cellulitis,  ii.  368 

exenteration  of,  ii.  371 

injuries,  ii.  368 

tumours  of,  ii.  369 
Orchitis,  acute,  ii.  653 

chronic,  ii.  654 

syphilitic,  ii.  656 

tuberculous,  ii.  655 
Os  calcis,  diseases,  i.  537 

fracture,  i.  345 
Os  magnum,  dislocation,  i.  298 
Osteitis  deformans,  i.  360 

diaphysitis,  i.  362-369 
See  Osteomyelitis 
Osteo-arthritis,  i.  412 

in  children  (Still),  i.  415 

gouty,  i.  416 

mon-articular,  i.  413 

polyarticular,  limited,  i.  414 
progressive,  i.  414 
Osteo-arthropathy,  pulmonary,  i.  359 
Osteoclasis,  manual  (tibia),  i.  530 
Osteogenesis  imperfecta,  i.  351 
Osteoma;  i.  95 

bone,  i.  379 
Osteomalacia  (cancerous),  i.  387 

(puerperal),  i.  358 


Osteomyelitis,  acute,  i.  363 

cystica  fibrosa  (v.  Recklinghausen),  i.  384 
Osteophytes,  i.  395 
Osteoplastic    flap,    exploration    of    brain,    i 

586 
Osteotomy,  ankylosis,  i.  397 

cuneiform,  i.  388 
(knee),  i.  527 

linear,  i.  388 

Macewen,  for  genu  valgum,  i.  527 
Otitis  media,  acute,  i.  609 

caries  of  temporal  bone,  i.  615 

chronic,  i.  611 

suppurative,  i.  611 

extradural  abscess,  i.  621 

facial  paralysis,  i.  613 

mastoiditis,  i.  614.     See  Mastoid 

operation  on  mastoid,  i.  617-620 

pachymeningitis,  i.  620 

subdural  abscess,  i.  623 

thrombosis  of  the  lateral  sinus,  i.  024 
Otosclerosis,  i.  612 
Ovarian  cysts,  ii.  345 

complications,  ii.  345 

diagnosis,  ii.  346 

torsion  of,  ii.  345 

treatment,  ii.  347 
Ovary,  cancer,  ii.  344 

tumours,  ii.  344 
Ozeena,  ii.  385 


Pachydermatoccele,  i.  93 

Paget,  "  eczema  of  nipple,"  ii.  6iSH 

Palate,  cleft-,  ii.  357.     Sec  Cleft-palate 

development,  ii.  354 

syphilis,  ii.  419 

tuberculosis,  ii.  419 

tumours,  ii.  420 
Palmar  arch,  ii.  61 

ganglion  (compound),  i.  424 
Pancreas,  calculi,  ii.  190 

cancer,  ii.  192 

cysts,  ii.  190 

exploration  of,  ii.  185 

fat  necrosis,  ii.  186 

injuries,  ii.  186 

pseudocysts,  ii.  186 
Pancreatitis,  acute,  ii.  186 

chronic,  ii.  189 
Panton,  gastric  analysis,  ii.  133 
Papillomas,  classification  of,  i.  79 

intracystic,  i.  81 

soft,  i.  81 
Paralysis,  anajsthetic,  i.  059 

in  children,  i.  552,  ooi 

crossed,  i.  583 

crutch,  i.  689 

Erb's,  i.  684 

facial,  i.  677 

(in  mastoiditis),  i.  613 

forearm,  i.  476 

in  lesions  of  the  spinal  cord,  i.  641 

"  Saturday  night,"  i.  689 

spastic,  i.  554 
Paraphimosis,  ii.  632 
Paraplegia,  i.  641 

from  spinal  disease,  i.  442,  445 
Parasyphilis,  i.  206 
Parathyroids,  ii.  486 
Parker,  tracheotomy  tube,  ii.  476 


£0 


INDEX 


Paronychia,  i.  483,  48-1 

Parosmia,  ii.  .'587 

Parotid,  tumours,  ii.  439,  44U 

Parotitis,  ii.  437 

Parrot,  nodes  on  skull  in  congenital  syphilis, 

i.  370 
Parry's  disease,  ii.  494 
Pasteur,  hydrophobia,  i.  184 
Patella,  dislocations,  i.  329 

fractures  of,  i.  326 
old-standing,  i.  328 
Patellar  bursae  (housemaid's  knee),  i.  523 

ligament,  i.  330 
Paul's  tube  (colostomy),  ii.  200 
Pelvic  abscess,  ii.  119 

cellulitis,  ii.  342 

hsematoccele,  ii.  339 

peritonitis,  ii.  342,  343 
Pelvis,  anatomy,  i.  302 

female  (anatomy),  ii.  337 

fractures,  i.  302 

injuries  to  viscera,  i.  303 

infections  (acute),  i.  489 

reniform  (rickets),  i.  355 

triradiate  (rickets),  i.  355 

tuberculosis,  i.  489 

tumours,  i.  490 
Penis,  amputation,  ii.  036 

anatomy,  ii.  628 

cancer,  ii.  033 

elephantiasis,  ii.  033 

fistula,  ii.  628 

injuries,  ii.  630 

ulceration,  ii.  033 

warts,  ii.  033.     Set  Prepuce 
Perforating  ulcer,  i.  55 
Pericardium,  adhesions,  ii.  701 

effusions,  purulent,  serous,  ii.  700,  701 
Perichondritis,  larynx,  ii.  470 
Pericolitis,  ii.  218 

tuberculous,  ii.  201 
Perinephritis,  ii.  545 
Periostitis,  acute,  i.  302 
Peritoneal  drainage,  ii.  117 

effusion,  ii.  126 

pouches,  ii.  118 

toilette,  ii.  94 

"  veils,"  ii.  263 
Peritoneum,  cancer  of,  ii.  126 

effusions  into,  nature  of,  ii.  116 

surgical  aspects  of,  ii.  87,  88 
Peritonitis,  chronic,  ii.  124 

diffuse,  ii.  112 

encysted,  ii.  118 

Fowler's  position  for,  ii.  97 

gonococcal,  ii.  118 

localized,  ii.  112,  118 

pelvic,  ii.  119 

pneumococcal,  ii.  118 

prognosis,  ii.  115 

puerperal,  ii.  342 

signs  of,  ii.  112 

subphrenic,  ii.  120 

treatment,  ii.  115 

tuberculous,  treatment,  ii.  125 
varieties,  ii.  124 

varieties,  ii.  110,  111 
Peritonsillar  abscess,  ii.  443 
Peri-urethral  abscess,  ii.  626 
Permanganate  of  potassium,  i.  140 
Peroneal  artery,  ii.  69 


Peroxide  of  hydrogen,  i.  146 
Pes  arcuatus,  i.  545 

cavus,  i.  545 

plantaris,  i.  545 

planus  (flat-foot),  i.  456 
Peters,  ectopia  vesica?  (operation),  ii.  560 
Phagedena,  i.  67 
Phalanges,  amputation,  i.  488 

(injuries  of),  i.  300,  301 
Pharyngitis,  acute,  ii.  441 

chronic,  ii.  444 

gangrenous,  ii.  442 

ulcerative,  ii.  441,  442 
Pharyngocoele,  ii.  402 
Pharyngotomy,  lateral  (Trotter),  ii.  479 

median,  ii.  479 
Pharynx,      abscess      (retropharyngeal),     ii. 
448 

diphtheria,  ii.  446 

infections,  ii.  447,  448 

(lower),  examination  of,  ii.  452-454 

syphilis,  ii.  448 

tuberculosis,  ii.  447 

tumours  of,  ii.  450 
Phelps'  box  (spinal  caries),  i.  444 
Phimosis,  ii.  030,  631 
Phlebitis,  simple,  ii.  39 

suppurative  and  infective,  ii.  40 
Phleboliths,  ii.  13 

diagnosis  from  ureteric  calculi,  ii.  527 
Phosphorus,  necrosis  of  jaw,  ii.  407 
Phrenic  nerve,  injury,  i.  081 
Phthisis,  surgery  of,  ii.  708 
Picric  acid,  for  burns,  i.  130 
Piles,  ii.  321 

••  sentinel,"  ii.  329 
Pirogoff,  amputation  (ankle),  i.  535 
Pituitary  extract  for  peritonitis,  ii.  117 

tumours,  operations  for,  i.  638 
Plantar  fascia  (ossification),  i.  550 

division  of,  i.  541 
Plaster  of  Paris  in  fractures,  i.  230 
Pleural  effusions,  ii.  704-707 
.Pleurodynia,  i.  694 
Plexus,  brachial,  i.  683 

cervical,  i.  681 

lumbar,  i.  695 

sciatic,  i.  695 
Plummet' .  exophthalmic  goitre,  ii.  497 
Pneumococcal  joints,  i.  401 

peritonitis,  ii.  118 
Pneumococci,  i.  171 
Pneumogastric  nerve,  i.  080 
Pneumonia  in  fractures,  i.  247 
Pneumothorax,  ii.  702 
Poliomyelitis,  anterior,  i.  552.  553 
Politzer,  inflation  of  middle  ear,  i.  604 
Polycystoma,  ovarian,  ii.  345 
Polypi,  aural,  i.  613 

nasal,  i.  97  ;  ii.  386 

nasopharyngeal,  ii,  396-397 
Popliteal  aneurysm,  ii.  38 

artery,  ligature,  ii.  65,  66 

bursae,  i.  524 

nerves,  i.  696 
Poroplastic  for  fractures,  i.  228 
Pott,  "  puffy  tumour  "  (skull),  i.  575 
Pott's  disease  (spine,  tuberculosis  of),  i.  437- 
447 

fracture,  i.  340 

Pregnancy,  ectopic,  ii.  338 


INDEX 


21 


Prepuce,  ii.  630-033 

See  Phimosis,  Paraphimosis 
Proctitis,  ii.  329 

See  Rectum,  affections  of 
Prostate,  abscess,  ii.  590 

adenoma  (anatomy  and  course),  ii.  592,  594 
catheter-life,  ii.  598 
treatment,  ii.  597-602 

anatomy,  ii.  588 

calculi,  ii.  588 

cancer,  ii.  602,  603 

enlargement  of,  ii.  592-602 
See  Adenoma 

inflammations,  ii.  589-591 

injuries,  ii.  588 

sarcoma,  ii.  603 

tuberculosis,  ii.  592 
Prostatectomy,  adenoma,  perineal,  ii.  601 
suprapubic,  ii.  599 

cancer,  ii.  603 
Protopathic  sensation,  i.  654 
Pruritus  ani,  ii.  328 
Psoas  abscess,  i.  441 
Ptosis,  i.  670,  683 
Ptyalism,  ii.  419 
Pudic  artery,  ii.  63 
Puerperal  infections,  ii.  341 
•Pulled  elbow,"  i.  289 
Pulmonary  embolus,  ii.  701 
Punch-fracture  (metacarpals),  i.  299 
Pupils,  alteration  in  cerebral  conditions,  i. 

583,  590 
Pus,  varieties  of,     .33 
Pyaemia,  i.  159 

signs  of,  i.  161 

treatment  of,  i  163 
Pysemic  joints,  i.  402 
Pyelitis,  ii.  540-543 

See  Kidney,  infections  of 

treatment,  ii,  541-543 
Pyelonephritis,  ii.  540-543 
Pylorectomy  for  cancer,  ii.  155 
Pyloric  stenosis,  congenital,  ii.  149 

fibrous,  ii.  149 
Pyloroplasty,  ii.  159 
Pyonephrosis,  ii.  543-544 

tuberculous,  ii.  548 
Pyorrhoea  alveolaris  (Rigg),  ii.  405 
Pyosalpinx,  ii.  342 


Quinsy,  ii.  442,  443 


Rabies,  i.  183 

Radial  artery,  ii.  61 

Radical  operation,  hernia,  ii.  289 

Si  i  Hernia,  operations 
Radiography,  see  X-rays 
Radium  for  tumours,  i.  105 
Radius,  congenital  dislocation  of  head,  i.  471 

diseases  of,  i.  477 

dislocation  of  head,  i.  289 

fracture,  head,  i.  291 
lower  end,  i.  295,  296 
shaft,  i.  292,  293 
Railway  spine  (Erichsen),  i.  633,  634 
Ranula,  ii.  439 

Raynaud's  disease  (gangrene),  i.  64 
Reaction  of  degeneration,  i.  640,  656 
Recto-vesical  fistula,  ii.  583 


Rectum,  abdominoperineal    operation    fnr 

cancer,  ii.  227 

abscesses  about,  ii.  330 

anal  fissure,  ii.  320 

anatomy,  ii.  317 

cancer  of,  ii.  227 

congenital  defects,  ii.  319 

examination,  ii.  318 

fistula  in  ano,  ii.  331 

gangrene,  ii.  331 

gonococcal  infection,  ii.  334 

haemorrhoids,  ii.  321 

imperforate,  ii.  319 

inflammation  of,  ii.  320 

injuries,  ii.  321 

papilloma,  ii.  336 

perineal  excision  for  cancer,  ii.  228 

polypus,  ii.  336 

prolapse,  ii.  327 

pruritus  ani,  ii.  328 

stricture,  ii.  335 

syphilis,  ii.  334 

tuberculosis,  ii.  329,  332 

ulcers,  ii.  329 
Rectus  femoris,  rupture  of,  i.  330 
Reid,  base  line  of  skull,  i.  579 
Renal  aneurysm,  ii.  5 1 5 

calculus,  pathology,  ii.  521.  .">22 
signs,  ii.  522,  528 
treatment,  ii.  529-534 
varieties,  ii.  519-521 

colic  (stone),  ii.  522 

disease,  relation  to  general  surgery,  i.  118 

fistula,  ii.  546 

function,  tests  of,  ii.  505 

mesothelioma,  i.  88  ;  ii.  551 

tumours,  i.  78 
Retro-peritoneal  bleeding,  ii.  109 

tumours,  ii.  130 
Retro-pharyngeal  abscess,  ii.  44S.  440 
Rheumatoid  arthritis,  i.  412 

spine,  i.  447 
Rhinitis,  acute,  ii.  383-384 
See  Nose,  Nasal 

atrophic,  ii.  3S4,  385 

hypertrophic,  ii.  385 

syphilitic,  ii.  384 
Rhinoliths,  ii.  381 
Rhinophyma,  ii.  379 
Rhinoscopy,  anterior,  ii.  377 

posterior,  ii.  377 
Ribs,  fracture,  ii.  696 

tuberculosis,  ii.  697 

tumours,  ii.  698 
Richter's  hernia,  ii.  30S 
Rickets,  i.  351 

bones,  changes  in,  i.  353 

cranio-tabes,  i.  354 

deformities  from,  i.  35 1 

delayed,  i.  350 

femur,  i.  355 

rosary  (thorax),  i.  355 

scoliosis,  i.  354 

tibia,  i.  355,  530 
Riders  bone,  i.  380 
Rigg,  pyorrhoea  alveolaris,  ii.  400 
Rigors,  i.  Ill 

Rhine,  test  of  hearing,  i.  605 
Rodent  ulcer,  i.  85 
Rolandic  area,  lesions  of,  i.  583 
Rolando  fissure  of  (brain),  i.  581 


22 


INDEX 


Roux,  femoral  hernia,  operation,  ii.  298 
Rovsing,  gastropexy,  ii.  265 
gastroscope,  ii.  133 

tuberculous  bladder,  ii.  577 
vaseline  for  rheumatic  knees,  i.  519 
Rupia,  i.  203 


Sacrococcygeal  tumour,  i.  644 
Sacro-iliac  joint,  tuberculosis,  i.  489 
Saddle  nose,  i,  207 
Saline  infusion,  i.  117 
Salivary  calculi,  ii.  435 

fistula,  ii,  434 

glands,  anatomy,  ii.  439 
infections,  ii.  436,  437 
ranula2,ii.  439 
tuberculous,  ii.  438 
tumours,  ii.  439,  440 

tumours,  i.  78 
Salpingitis,  ii.  342 
Salvarsan,  i.  212 

Sapraemia,  i.  14,  160.     See  Bacteria 
Sarcoma,  bone,  i.  381 
treatment,  i.  386 

in  fractures,  i.  247 

giant-celled,  i.  95 
(of  bone),  i.  383 

lympho-,  ii.  85 

mixed-celled,  i.  100 

varieties,  i.  97-99 
Sayre,  plaster  jacket  (spinal  caries),  i.  444 

strapping,  fractured  clavicle,  i.  260 
Scalds,  i.  129 
Scalp,  abscess,  i.  561 

cellulitis,  i.  561 

erysipelas,  i.  561 

hematomas,  i.  559 

syphilis,  i.  561 

tumours  of,  i.  361-363 

wounds,  i.  560 
Scaphoid  (carpal),  fracture,  i.  297 

(tarsal),  fracture,  i.  346 
Scapula,  congenital  defects,  i.  461 

excision  of,  i.  462,  463 

fracture  of,  i.  265-267 

tumours  of,  i.  462 

"  winged,"  i.  462 
Scarlatina,  joint  affections  in,  i.  400 
Schaudinn,  spirochete  of  syphilis,  i.  197 
Schede,  empyema  (operation),  ii.  707 
Schlatter  (injuries  to  upper  tibial  epiphysis), 

i.  325 
Schwartze  (antral  drainage  of  otitis  media), 

i.  617 
Sciatic  artery,  ii.  37,  63 

nerve,  i.  695 
Sciatica,  i.  697 

Sclavo,  serum  for  anthrax,  i.  177 
Scoliosis,  i.  436,  448 

anatomy,  i.  450 

diagnosis,  i.  452 

rickets,  i.  354 

treatment,  i.  453 
Scrotum,  cancer,  ii.  664 

cellulitis  (extravasation  of  urine),  ii.  626, 
627 

eczema,  ii.  662,  663 

elephantiasis,  ii.  663 

erysipelas,  ii.  663 

injuries,  ii.  640 


Scurvy,  infantile,  i.  357 
Sebaceous  carcinoma,  i.  562 

cysts,  i.  109 
Semilunar  cartilages  (of  knee),  injuries,  i.  331 
Semi-membranosus  bursa,  i.  524 
Semon,  excision  of  larynx,  ii.  480 
Senn,  gastrostomy,  ii.  158 
Sensation,  loss  of,  in  spinal  cord  lesions,  i.  641 
types  of  (Head  and  Sherren),  i.  640 
varieties  of,  i.  654.     See  Nerves 
"  Sentinel  "  pile,  ii.  329 
Septic  intoxication,  i.  160 
Septicaemia,  i.  14,  159.     See  Bacteria 

treatment  of,  i.  160 
Sequestrotomy,  i.  369 
Sequestrum,  i.  348 
Serum-therapy,  i.  18 
Serratus  magnus  (paralysis),  i.  462,  687 
Sharpe,  splint  for  Pott's  fracture,  i.  342 
Sherren,  cervical  ribs  (diagnosis),  i.  457 
incomplete  R.D.,  i.  656 
nerves  (recovery  of  function),  i.  662 
sensation  (types  of),  i.  640 
(varieties),  i.  654 
Shock,  cerebral,  i.  587 
pathology  of,  i.  115 
signs  of,  i.  114 
treatment  of,  i.  116 
Shoulder,  amputation  at,  i.  468 
ankylosis,  i.  466 
arthrotomy,  i.  466 
aspiration  of,  i.  466 
diagnosis  of  injuries,  i.  264 
excision  of,  i.  466 
joint,  acute  infections,  i.  464 
anatomy  of,  i.  262 
arthrodesis,  i.  464 
dislocations,  congenital,  i.  463 
old-standing,  i.  273 
paralytic,  i.  463 
recurrent,  i.  274 
reduction,  i.  270,  etc. 
(traumatic),  i.  268-273 
"  flail,"  i.  463 
fracture  dislocations,  i.  279 
sprains  of,  i.  267 
tuberculosis,  i.  464 
operations  on,  i.  466 
rheumatoid  arthritis,  i.  465 
tuberculosis,  i.  465 
Sigmoidoscope,  ii.  319 
Sinus,  i.  39 

(accessory  of  nose),  ii.  3oS-39J 
pyriformis,  cancer,  ii.  472 

foreign  bodies,  ii.  465 
thrombosis,  i.  623. 

See  Brain,  Otitis  media 
treatment  of,  i.  40 
Skey,  amputation  (tarso-metatarsal),  i.  556 
Skin  grafting,  i.  53 

Skull,  affections  of,  i.  565-57S.     Scr  Cranium 
fractures,  i.  566-574 
landmarks  on,  i.  579 
syphilis  of,  i.  375 
tumours  of,  i.  577 
Smith,   Stephen,   amputation   at   the   knee, 

i.  529 
Soft  sore,  i.  173 

Spence,  amputation  at  the  shoulder,  i.  468   J 
Spencer,    treatment    of    old-standing    dis- 
locations'of  the  shoulder,  i.  273 


INDEX 


23 


Spermatic   cord,   inflammation   (funiculitis), 
ii.  649 
injuries,  ii.  641,  642 
tumours  of,  ii.  651 
varicoccele,  ii.  650 
Spermatoccele,  ii.  649 

See  Hydrocoele,  scrotal. 
Sphenoidal  sinus,  ii.  393,  394 
Spina  bifida,  i.  642 
Spinal  accessory  nerve,  i.  680 
cord,  anatomy,  i.  639 
complete  section,  i.  641 
concussion,  i.  648 
diagnosis  in  general,  i.  639,  640 
exploration  of,  i.  642 
fractured  spine  (results),  i.  647 
haemorrhage  around,  i.  648 
hemisection  of,  i.  641 
injuries  of,  i.  648,  649 
operation  for,  i.  651 
treatment,  i.  650 
meningitis,  acute,  i.  649 
meningocoele,  i.  643 
myelitis,  i.  649,  652 
myeloccele,  i.  643 
spina  bifida,  i.  642 
syringo-myelia,  i.  653 
syringo-myeloc  cele,  i.  643 
tumours  of,  i.  653 
Spine,  caries  of,  i.  437-447 
dislocations,  i.  645,  646 
examination  of,  i.  436 
fracture,  i.  645,  646 
signs,  i.  646-648 
osteomyelitis,  acute,  i.  436 
punctured  wounds,  i.  645 
rheumatoid  affections,  i.  447 
scoliosis,  i.  448.     See  Scoliosis 
sprains,  i.  645 
static  deformities,  i.  448 
syphilis,  i.  447 
tuberculosis,  i.  437-447 
abscess  in,  i.  440 
operative    treatment    (Albee,     Hibbs), 

i.  446 
paralysis  in,  i.  442 
paraplegia,  treatment,  i.  445 
signs  of,  i.  439 
treatment  of,  i.  443-447 
tumours  of,  i.  456 
typhoid  affecting,  i.  447 
Spirochseta  pallida,  i.  197 
Splay-foot  (flat-foot),  i.  546 
Spleen,  abscess,  ii.  193 
enlargement  of,  ii.  194 
excision  of,  ii.  195 
floating,  ii.  193 
injuries,  ii.  192 
wandering,  ii.  193 
Splenectomy,  ii.  195 
Splenic  anaemia,  ii.  194 
Splints,  i.  230,  231 

See  also  Special  fractures 
Sprains  and  sprain  fractures,  i.  248 

wrist,  i.  294 
"  Spreadeagle "     position,     congenital     dis- 
location of  hip,  i.  498 
Sprengel,  deformity  of  scapula,  i.  461 
Stacke,  mastoidectomy,  i.  617-620 
Staphylococcal  infections,  i.  164 
Staphylococci,  L  161 


Steam,  superheated  for  sterilizing,  i.  145 
Steinmann,     nail-extension     for     fractures 

i.  314 
Stenson's  duct  (injuries),  ii.  434 
Stercoral  ulcers,  ii.  282 

Sterilized  materials  for  operation,  i.  148,  149 
Sterilization  by  heat,  i.  145 
Sterno-clavicular  joint,  diseases  of,  i.  460 

injuries  of,  i.  258 
Sterno-mastoid  muscle  (torticollis),  i.  458, 459 
Sternum,  fracture,  ii.  696 
syphilis,  ii.  697 
tumour,  ii.  698 
Still,  osteo-arthritis  in  children,  i.  415 
Stokes,  amputation  of  knee  (supracondylar) 

i.  528 
Stomach,  abscess  of,  ii.  136 
bismuth  meal,  ii.  133 
cancer,  ii.  151 
signs  of,  ii.  153 
spread  of,  ii.  152 
treatment  of,  ii.  155 
corrosive  fluids  in,  ii.  135 
dilatation,  acute,  ii.  148 

chronic,  ii.  148,  149 
examination,  ii.  133 
foreign  bodies  in,  ii.  134 
gastroscope  (Rovsing),  ii.  133 
hair-balls  in,  ii.  135 
hour-glass,  ii,  144,  145 

gastrojejunostomy  for,  ii.  147 
inflammation  of,  ii.  136 
"  leather-bottle,"  ii.  1? 
operations  on,  ii.  135 
for  cancer,  ii.  155 
Finney's,  ii.  160 
gastro-gastrostomy,  ii.  147 
gastrojejunostomy,  ii.  160 
See  Gastroenterostomy 
gastroplasty,  ii.  146 
gastroplication,  ii.  160 
gastrorrhaphy,  ii.  160 
gastrostomy,  ii.  157 
gastrotomy,  ii.  157 
lavage,  ii.  156 
pyloroplasty,  ii.  159 
stenosis  of,  ii.  144 
test  meals,  ii.  133 
ulcers  of,  i.  136 
acute,  ii.  137 
chronic,  ii.  137 
wounds  of,  ii.  134 
Stomatitis,  aphthous,  i'  417 
catarrhal,  ii.  417 
gangrenous,  ii.  418 
mercurial,  ii.  418     ^ 
ulcerative,  ii.  418 * 
Storrs,  infra-orbital  nerve  (exposure),  i.  673 
Stovaine  (spinal  anaesthesia),  i.  141 
Strabismus,  i.  670 
Strangulated  hernia,  ii.  308 
Strangury,  ii.  523,  57'  ] 
Streptococci,  i.  167 
Streptothrices,  i.  192 
Stricture  (urethral),  ii.  6U-627  ] 

See  Urethra 
String-saw  (Abbe),  ii.  460 
Subastragaloid,  amputation,  i.^586] 
Subclavian  aneurysm,  ii.  36 

(artery,  ii.  56   „■ 
Subdeltoid  bursa,  inflammation,  i.  465 


24 


INDEX 


Sublingual  abscess,  ii.  422,  431 
Submaxillary  cellulitis,  ii.  434 

tumours,  ii.  439 
Subnormal  temperature,  i.  Ill 
Subphrenic  abscess,  ii.  120 
Sunstroke,  i.  132 
Suppuration,  see  Abscess 
anatomy,  i.  32 
course  of,  i.  37 
general  effects  of,  i.  35 
sequelae  of,  fistula,  i.  39 
sinus,  i.  39 
ulceration,  i.  39 
signs  of,  i.  35 
treatment  of,  i.  38 
varieties  of,  i.  33 
Surgical  emphysema,  ii.  090 
Sutures,  preparation  of,  i.  149 
Sylvian  fissure  (brain),  i.  580 
Syme,  amputation  (ankle),  i.  534 
excision  of  tongue,  ii.  432 
repair  of  nose,  ii.  380 
Symondss  tubes  for  stricture  of  oesophagus, 

ii.  460,  462 
Syncope,  signs  of,  i.  115 
Synovitis,  i.  390 
acute,  i.  391 
cbronic,  i.  392 
Syphilides,  i.  203 
Syphilis,  acquired,  i.  198 
bones,  i.  374 
bursse,  i.  428 
congenital,  i.  200 

affections  of  the  eye,  i.  20S 
diagnosis,  i.  201,  209 

tertiary,  i.  204 
epiphysitis,  i.  207 

congenital,  i.  376 
infectivity  of,  i.  211 
joints,  i.  411 
muscles,  i.  421 

Parrot's  nodes  of  skull,  i.  370 
pathology,  i.  197 
primary,  i.  197 
prognosis,  i.  210 
prophylaxis,  i.  211 
pseudo-paralysis,  i.  370 
secondary,  i.  202 

of  deeper  structures,  i.  204 
skull,  i.  375 
spine,  i.  447 
tendon-sheaths,  i.  424 
tertiary,  i.  205 

treatment  of,  arsenic  compounds,  i.  212 
congenital,  i.  215 
iodides,  i.  214 
mercury,  i.  213 
neosalvarsan,  i.  2  I L' 
results  of,  i.  215 
salvarsan,  i.  212 
Syringo-myelia,  i  653 

joints,  i.  410 
Syringo-myelocoele,  i.  043 


Tabes,  joints  in  (Charcot),  i.  416 
Talipes,  causes,  i.  539 

congenital  (calcaneus),  i.  542 
(equino- varus),  i.  539 
treatment,  i.  542 
diagnosis  of  cause,  i.  549 


Talipes,  excision  of  astragalus,  i.  532 

hysterical,  i.  549 

paralytic,  i.  543,  544 

Phelps'  operation,  i.  542 

tarsectomy  in,  i.  542 
Talma,  epiplopexy,  ii.  127 
Tarsectomy,  i.  533 
Tarso-metatarsal  amputation,  i.  556 
Tarsus,  gonorrhceal  infection,  i.  537 

osteomyelitis,  i.  537 

tuberculosis,  i.  537 
Taxis  (strangulated  hernia),  ii.  310 
Teeth,  caries,  ii.  402 

eruption  of  abnormal,  ii.  404 

extraction,  ii.  404 

fracture,  ii.  399 
Telling,  nodular  fibromyositis,  i.  421 
Temporal  artery,  ii.  56 
Temporo-maxiuary  joint,  diseases,   ii.   412. 
413 

dislocation,  ii.  401 
Tendo  Achillis,  tenotomy,  i.  555 
Tendon,  dislocation  of,  i.  255 

inflammation  of,  i.  422,  423 

operations  on,  i.  425,  420 

reinforcement,  i.  426 

rupture  of,  i.  253 
Tennis  leg,  i.  337 

Tenosynovitis,  varieties,  i.  422-423 
Tenotomy,  i.  425 

foot,  i.  554 

hamstrings,  i.  528 
Teratoblastomas,  i.  09.  78 

renal,  i.  78 

salivarv,  i.  78 
Teratoma",  i.  3,  09,  77 

testicular,  i.  77 
Testis,  anatomy,  ii.  037 

See  also  Hydrocele,  Varicocele 
atrophy,  ii.  661 
descent  of  (anomalies),  ii.  280 
ectopic,  ii.  039 
fungus,  ii.  061 
inflammations,  ii.  052.  050 

See  Orchitis.  Epididymitis 
injuries,  ii.  641 
neuralgia,  ii.  062 
torsion  of,  ii.  639 
tumours  of,  ii.  058-001 
undescended,  ii.  638 
with  hernia,  ii.  282 
Tetanus,  i.  180 

head-,  or  hydrophobicus,  i.  181 
Tetany  in  dilated  stomach,  ii.  146 
Thermic  fever,  see  Sunst  roke 
Thiersch,  skin-grafting,  i.  5:5 
Thigh,  amputation  through,  i.  514 
Thomas's  calliper  splint  (knee),  i.  314 
splint  (for  tuberculous  spine),  i.  443 
Thoracic  duct,  rupture  of,  ii.  7:{ 
Thorax,  anatomy,  ii.  094 
compression  cyanosis,  ii.  095 
injuries,  ii.  i>9.~«.  697 
Thrombi,  fate  of,  ii.  13 

varieties  of.  ii.  13 
Thrombosis,  ii.  13 
mesenteric,  ii.  129 
results  of.  ii.  14 
sinuses  of  skull,  i.  023.  etc. 
Thumb  dislocation,  i.  298-300 
fractures  of,  i.  298-300 


INDEX 


25 


Thymus,  surgery,  ii.  485 
Thyroglossal  cyst  and  fistula,  ii.  307 
Thyroid  gland,  anatomy,  ii.  480 
acute  goitre,  ii.  490 
adenomatous,  ii.  -is1.) 
cystic,  ii.  489 

exophthalmic  goitre,  ii.  494-497 
fibrous  goitre,  ii.   ts'.i 
infections  (thyroiditis),  ii.  487 
malignant  tumour,  ii.  493 
operations  on.  ii.  492,  493 
parenchymatous  goitre,  ii.  488 
results  of,  ii.  490 
vascular  -nitre,  ii.  489 
Thyrotomy  (median  laryngectomy),  ii.  480 
Tibia,  abscess,  chronic  (Brodie),  i.  529 
fractures,  lower  end,  i.  340 
shaft,  i.  334 
spine  of,  i.  324 
upper  end,  i.  324 
osteoclasis,  manual,  i.  530 
osteomyelitis,  i.  529 
rickets,  i.  355,  530 
sabre  (congenita]  syphilis),  i.  370 
sj  philis,  i.  530 
tumours,  i.  530 

upper  epiphysis,  separation,  u  324 
Tibial  arteries,  ii.  07 
Tic  douloureux,  i.  671 
Tidy,  gastric  analysis,  ii.  133 
Tinnitus,  i.  605 
Toe-nail,  ingrowing,  i.  552 
Toes,  affections  of,  i.  550-552 

amputation,  i.  556 
Tongue,  abscess,  ii.  -J 22 
actinomycosis,  ii.  420 
anatomy,  ii.  420 
cancer,  ii.  427-434 
diagnosis,  ii.  428,  429 
operation,  ii.  430-434 
cysts,  ii.  420 
dermoids,  ii.  -127 
excision,  ii.  432 
inflammation,  ii.  421,  420 

-S<  e  (ilossitis  and  Stomatitis 
nervous  affections,  ii.  421 
sublingual  abscess,  ii.  426 
syphilis,  ii.  425 
thyroid  tumours,  ii.  420 
tuberculosis,  ii.  424 
tumours,  innocent,  ii.  420 
ulcers,  ii.  422,  423 
Tonsil,  excision  of  (for  malignant  growth), 
ii.  451 
hypertrophy,  ii.  445 
lingual,  ii.  425 
removal  of,  ii.  445,  440 
tuberculosis,  ii.  447 
tumours  of,  ii.  451 
Tonsillar  sepsis,  ii.  445 
Tonsillitis,  ii.  440 
follicular,  ii.  442 

suppurative  peri-  (quinsy),  ii.  442 
Torticollis,  acute,  i.  458 
clonic,  i.  681 
congenital,  ii.  458 
Tourniquet  in  amputations,  i.  430 
Trachea,  stenosis,  ii.  473,  492,  493 

foreign  bodies,  ii.  465 
Tracheotomy,  difficulties,  ii.  476,  477 
high,  ii.  475 


Tracheotomy,  low,  ii.  476 
Transplantation,  sartorius  to  patera,  i.  528 

tendons  and  muscles,  i.  555 
Transpleural    route    to     oesophagus,    lung, 

heart,  ii.  711 
Trendelenberg,  operation  for  varix,  ii.  44 
Trephining,  exploration,  i.  5S5 

fractured  skull,  i.  570 

middle  meningeal  haemorrhage,  i.  5'.)4 
Treponema  pallidum,  i.  1<J7 
Trigeminal  nerve,  i.  070 
Triple  displacement  (knee),  i.  517 
Trotter,  lateral  trans-thyroid  pharyngotomy, 

ii.  479 
Trusses,  femoral,  ii.  2'JO 

inguinal,  ii.  286 
Trypanosomes,  i.  196 
Tuberculin,  i.  192 
Tuberculosis,  anatomy  of,  i.  187 
S< '  special  organs 

bone,  i.  371 

bursa?,  i.  428 

diagnosis  of,  i.  189 

infection  with,  i.  185 

intestine,  ii.  201 

joints,  i.  405-410 

muscles,  i.  421 

predisposition,  i.  186 

spread  of,  i.  189 

spinal,  i.  437-447 

tendon-sheaths,  i.  423 

treatment  of,  i.  190 
Tuberculous  glands,  ii.  81,  82,  83 
mesenteric,  ii.  129 

peritonitis,  ii.  124 
Tumours,  abdominal  wall,  ii.  269 
See  special  regions  and  organs 

aetiology  of,  i.  72 

atypical,  i.  70 

classification,  i.  69,  71,  101 

diagnosis  of,  i.  103 

Grawitz,  i.  88 

innocent,  i.  74 

lymph  glands,  secondary,  ii.  80 

of  lymphatics,  ii.  77 

malignant,  i.  74 

metastasis  of,  i.  75 

nutrition  of,  i.  77 

"  phantom,"  ii.  270 

renal,  i.  78 

retroperitoneal,  ii.  130 

stroma  of,  i.  70 

treatment  of,  by  (Joley's  fluid,  i.  105 
innocent,  i.  103 
malignant,  i.  104 
by  radium,  i.  105 

typical,  i.  70 
Turbinates,  operations  on,  ii.  380 
Turtle,  cancer  of  rectum,  ii.  229 
"  Two-glass  "  test  (urine,  pus),  ii.  502 
Tympanum,  injuries,  i.  608 
Typhoid  changes  in  bone,  i.  378 

joints,  i.  401 

spine,  i.  447 

ulcers,  ii.  200 


Ulcers,  i.  39 
anatomy  of,  i.  45 
callous,  i.  49 
causes  of,  i.  40 


26 


INDEX 


Ulcers,  chronic,  i.  49 

classification  of,  from  condition,  i.  47 

decubitus,  i.  54 

dental,  ii.  423 

duodenal,  ii.  137 

dysenteric,  ii.  202 

eczeniatous,  i.  50 

gastric,  ii.  130 

gouty,  i.  57 

hypertrophic,  i.  40 

intestine,  ii.  100 

jejunal,  ii.  167 

perforating,  i.  55,  538 

pressure,  i.  54 

results  of,  i.  49 

rodent,  i.  85 

excision  of  eye  for,  ii.  369 
scorbutic  (scurvy),  i.  57 
serpiginous,  i.  205 
stationary,  i.  40 
stercoral,  ii.  202 
syphilitic,  i.  57,  205 
traumatic,  i.  54 
treatment  of,  i.  50 

skin-grafts,  i.  52,  53 
trophic,  i.  55 

tuberculous,  i.  57  ;  ii.  201 
varicose,  i.  50 
Ulna,  disease  of,  i.  477 
dislocations  of.  i.  200 
fraotures,  coronoid,  i.  201 

olecranon,  i.  2(J0 

shaft,  i.  202.  203 

styloid,  i.  296 
Umbilical  cysts,  ii.  271 
fistula?,  ii.  271 
hernia,  ii.  200 

See  Hernia,  umbilical 
polypi,  ii.  270 
Unna,  treatment  of  ulcers,  i.  50 
Ursemia,  see  Renal  function 
TTreter,  calculi,  ii.  528 
congenital  defects,  ii.  511.     See  Kidney 
efflux,  ii.  505 
"  golf  hole,"  ii.  504 
injuries,  ii.  514 

operation  of  stone,  ii.  531,  532 
X-ray  examination,  ii.  525,  520 
Urethra,  abscess  (peri-urethral),  ii.  02(.i 
false  passages,  ii.  018 
fistula,  ii.  027 
foreign  bodies,  ii.  610 
hypospadias,  ii.  005 
inflammation  (urethritis),  ii.  610-  (ill 

See  Gonorrhoea 
injuries,  ii.  OOU-blU 
(male),  anatomy,  ii.  003,  C04 

cancer,  ii.  028 

congenital  defects,  ii.  604-tiOG 
stricture,  false  or  functional,  ii.  014 

investigation,  ii.  617,  618 

organic,  ii.  615,  027 

complications,  ii.  625-tiL\s 
•excision,  ii.  U24 
treatment,  ii.  620-025 
ulcer  (gonorrhoea),  ii.  613 
Urethritis,  posterior,  ii.  014 
See  Urethra,  Gonorrhoea 
Urethrotomy,  external,  ii.  023 

internal,  ii.  021 
Urinary  asepsis,  ii.  506,  507 


Urinary  cases,  examination,  ii.  408-505 

instruments,  ii.  506,  507 
Urine,  albuminuria,  ii.  400     - 

blood  in,  ii.  501,  502 

deposits  in,  ii.  500,  501 

examination  of,  ii.  490-502 

extravasation  of  (renal  injuries),  ii.  512 
ruptured  urethra,  ii.  608-610 
(stricture),  ii.  626 

glycosuria,  ii.  499 

incontinence  of,  ii.  584-580 

indigo  carmine  test,  ii.  504,  5U5 

pus  in,  ii.  501,  502 

residual,  ii.  586 

retention  of,  ii.  3u[,  502,  580-588 
(stricture),  ii.  625 

suppression  of,  ii.  5U0 
Uterine  fibroids,  ii.  348 

Uterus,  cancer,  ii.  351 

infection*  puerperal,  ii.  341 

removal  of,  ii.  351.     See  Hysterectomy 

tumours  of,  ii.  348-352 


Vaccines,  i.  17 

V.  Hook,  ureter  (suture  of),  ii.  514 

Varicoccele,  ii.  050 

Varicose  aneurysm,  ii.  21.  -1 

ulcers,  i.  50 
VariX,  causes  of,  ii.  41 

treatment  of,  ii  13 
Veins,  air  embolism  in,  ii.  20 

inflammation  of,  set  Phlebitis 

injuries  of.  ii.  20 

jugular,   ligature  lor  latent     sinus    throm- 
bosis, i.  o-.; 

operation  on,  ii.  69 

varicose,  see  Varix 
Vertebral  artery,  ii.  57 
Vertigo,  auditory,  i.  606 

Vesical  (stones,  tumours,  etc.).  ii.  .v>s.  etc. 

See  Bladder 
Vesiculse  seminales,  inflammation,  ii.  002 

tuberculosis,  ii.  592,  002 
ViciOUS  circle,  gastrojejunostomy,  ii.  100 

Visceroptosis,  ii.  203-205 
Vincent's  organisms  in  Xoma.  etc..  i.  178 
Virchow,  chondxo-arthritis  (syphilitic),  i.  411 
Volkmann's  contracture,  i.  243,  255 
Volvulus,  ii.  230 

treatment  of,  ii.  255 
Vomiting,  cerebral,  i.  582 

gastric,  ii.  120 

intestinal  obstruction,  ii.  233 
v.  Bruning,  bronchoscope,  ii.  453 
v.  Pirquet,  tuberculin  reaction,  i.  190 
v.  Recklinghausen,  cysts  of  bone,  i.  384 

disease,  l.  92,  94 
(nerves),  i.  008 

Walton,  box  splint,  i.  319 

Wardrop,  treatment  of  aneurysm,  ii.  29 

Warts,  i.  80 

anatomical,  i.  450 
Wassermann's  reaction,  i.  158,  198,  206 

Set  a/so  Syphilis 
Weber,  test  of  hearing,  i.  605 
Wertheini,  hysterectomy,  ii.  352 
Wheelhouse,  urethrotomy  (external),  ii.  023 
White  swelling  (tubwiculous  joint),  I.  4U7 


INDEX 


27 


White,  Hayle,  exophthalmic  goitre,  ii.  496 
Whitehead,  excision  of  haemorrhoids,  ii.  327 

tongue,  excision,  ii.  432 
Whitlow,  i.  is:;   is:, 

Whitman,  abduction  for   fractures   of   neck 
of  femur,  i.  317 

epiphysis  of  upper  end  of  humerus  (treat- 
ment), i.  217 

flat-foot,  i.  456 
Widal's  reaction,  i    157 
Wilms  caecopexy,  ii.  265 

tumour  (kidnej  .  ii.  55] 
Witzel,  gastrostomy,  ii.  L58 
Wounds,  abdomen,  ii,  100-108 

amputation  for,  i.  125 

gunshot,  i.  L27,  128 

lacerated,  i.  124 

shot-guns,  i.  L28 

stomach,  ii.  1 3  f 


Wounds,  varieties  of,  i.  123 
Wrist,  amputation,  i.  479 

deformities,  i.  477 

dislocations,  i.  297 

excision  of,  i.  478 

tuberculosis,  i.  47.S 
Wryneck,  i.  458.     See  Torticollis 


X-iays,  fractures,  i.  227 
oesophagus,  ii.  450 
renal  calculus,  ii.  524-527 
for  tumours,  i.  105 


Yaws,  i.  210 

Yearcley,  artificial  drum,  i.  612 

Young,  prostate,  cancer  excision,  ii.  603 


tALLASTTSE,    HANSOM    S-    CO.    LTD. 
LONDON    AND    EDINBURGH 


I  ' 


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